Provider Demographics
NPI:1669492690
Name:SPARKS, EDWIN WAYNE JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:WAYNE
Last Name:SPARKS
Suffix:JR
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 BILLINGSLEY RD
Practice Address - Street 2:STE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1009
Practice Address - Country:US
Practice Address - Phone:704-444-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401342208200000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN42094Medicaid
NC1669492690Medicaid
NC8978566Medicaid
NC2205894DMedicare PIN
SCN42094Medicaid
NC8978566Medicaid