Provider Demographics
NPI:1629205133
Name:MODERN URODYNAMICS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:MODERN URODYNAMICS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-654-0356
Mailing Address - Street 1:7855 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-5344
Mailing Address - Country:US
Mailing Address - Phone:323-654-0356
Mailing Address - Fax:323-297-5220
Practice Address - Street 1:7855 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5344
Practice Address - Country:US
Practice Address - Phone:323-654-0356
Practice Address - Fax:323-297-5220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103568208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty