Provider Demographics
NPI:1568466035
Name:DALLAS FAMILY PRACTICE CENTER PA
Entity Type:Organization
Organization Name:DALLAS FAMILY PRACTICE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:SPARTI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-445-1095
Mailing Address - Street 1:PO BOX 89
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0002
Mailing Address - Country:US
Mailing Address - Phone:770-445-1095
Mailing Address - Fax:770-445-5361
Practice Address - Street 1:318 MAIN ST
Practice Address - Street 2:STE B
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-4266
Practice Address - Country:US
Practice Address - Phone:770-445-1095
Practice Address - Fax:770-445-5361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-12
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00063764AMedicaid
GAD30877Medicare UPIN
GA265789039AMedicare ID - Type Unspecified