Provider Demographics
NPI:1629076153
Name:SPARKS, DENNIS A (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:A
Last Name:SPARKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2831 S HURSTBOURNE PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-4121
Mailing Address - Country:US
Mailing Address - Phone:502-491-6963
Mailing Address - Fax:502-491-8398
Practice Address - Street 1:2831 S HURSTBOURNE PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-4121
Practice Address - Country:US
Practice Address - Phone:502-491-6963
Practice Address - Fax:502-491-8398
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY26281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY611339454OtherTIN
KY611339454OtherTIN
KYE39220Medicare UPIN