Provider Demographics
NPI:1568584019
Name:SPARKS, KENDRICK LADEL (MD)
Entity Type:Individual
Prefix:DR
First Name:KENDRICK
Middle Name:LADEL
Last Name:SPARKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KENDRICK
Other - Middle Name:LADEL
Other - Last Name:SPARKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-649-2863
Mailing Address - Fax:
Practice Address - Street 1:215 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2705
Practice Address - Country:US
Practice Address - Phone:601-249-5500
Practice Address - Fax:601-249-1714
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24476208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02589533Medicaid