Provider Demographics
NPI:1407983505
Name:SPARKMAN, THOMAS C (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:SPARKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-388-3939
Mailing Address - Fax:573-334-5554
Practice Address - Street 1:60 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4928
Practice Address - Country:US
Practice Address - Phone:573-388-3939
Practice Address - Fax:573-334-5554
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2453207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200255206Medicaid
MODA4814OtherRAILROAD MEDICARE
MODA4814OtherRAILROAD MEDICARE
MO200255206Medicaid