Provider Demographics
NPI:1316045677
Name:SPARKS, ROBERT W (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:SPARKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1085
Mailing Address - Street 2:2200 S HALLIBURTON
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-1085
Mailing Address - Country:US
Mailing Address - Phone:660-627-1560
Mailing Address - Fax:660-665-0533
Practice Address - Street 1:2200 S HALLIBURTON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4651
Practice Address - Country:US
Practice Address - Phone:660-627-1560
Practice Address - Fax:660-665-0533
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9D41207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO25936OtherBLUE CROSS BLUE SHIELD
MO4419174OtherAETNA
MO136077OtherHEALTHLINK
MO242000339Medicaid
MO010047006OtherRAILROAD MEDICARE
MO242000339Medicaid
MO010047006OtherRAILROAD MEDICARE
MO001013411Medicare PIN