Provider Demographics
NPI:1336132497
Name:SPARKS, BERNARD I III (OD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:I
Last Name:SPARKS
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2211
Mailing Address - Country:US
Mailing Address - Phone:901-722-3250
Mailing Address - Fax:901-722-3347
Practice Address - Street 1:1225 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2211
Practice Address - Country:US
Practice Address - Phone:901-722-3250
Practice Address - Fax:901-722-3347
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00103804OtherRAILROAD MEDICARE
TN35970641Medicaid
TN641OtherOD
TN3597066Medicaid
TN4176592OtherBLUE CROSS BLUE SHIELD OF TENNESSEE
MS0108286OtherDEA
TN35970641Medicare PIN
TN641OtherOD
TN3597065Medicare ID - Type Unspecified
TN35970641Medicaid