Provider Demographics
NPI:1629079678
Name:SPARKS, LEE BRADFORD (MD)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:BRADFORD
Last Name:SPARKS
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 1:480 HOPKINSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42345-1124
Mailing Address - Country:US
Mailing Address - Phone:270-338-5777
Mailing Address - Fax:270-338-5765
Practice Address - Street 1:480 HOPKINSVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1124
Practice Address - Country:US
Practice Address - Phone:270-338-5777
Practice Address - Fax:270-338-5765
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35030207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64038474Medicaid
H40941Medicare UPIN
KY64038474Medicaid