Provider Demographics
NPI:1720602295
Name:SPARKS, NATHANIEL THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:THOMAS
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 1:26 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MS
Mailing Address - Zip Code:38827-7737
Mailing Address - Country:US
Mailing Address - Phone:662-454-4520
Mailing Address - Fax:662-454-4521
Practice Address - Street 1:26 3RD ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MS
Practice Address - Zip Code:38827-7737
Practice Address - Country:US
Practice Address - Phone:662-494-4520
Practice Address - Fax:662-494-4521
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS29376207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine