Provider Demographics
NPI:1518316694
Name:SPARKS, BRADLEY DOMINICK (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DOMINICK
Last Name:SPARKS
Suffix:
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 1:30 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-1905
Mailing Address - Country:US
Mailing Address - Phone:570-282-4080
Mailing Address - Fax:
Practice Address - Street 1:30 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-1905
Practice Address - Country:US
Practice Address - Phone:570-282-4080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003190152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist