Provider Demographics
NPI:1710113733
Name:SPARKS, NEIL LESLIE (DO)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:LESLIE
Last Name:SPARKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 BONBROOK DR
Mailing Address - Street 2:WFBH FAMILY MEDICINE-REYNOLDA
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3020
Mailing Address - Country:US
Mailing Address - Phone:336-713-5393
Mailing Address - Fax:
Practice Address - Street 1:3020 BONBROOK DR
Practice Address - Street 2:WFBH FAMILY MEDICINE-REYNOLDA
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3020
Practice Address - Country:US
Practice Address - Phone:336-713-5393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01633207Q00000X, 207QS0010X
WV2612207QS0010X
VA0102203069207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine