Provider Demographics
NPI:1891771127
Name:SPARKS JENET, TAMMY (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:
Last Name:SPARKS JENET
Suffix:
Gender:F
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 2699
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20195-0699
Mailing Address - Country:US
Mailing Address - Phone:703-471-0919
Mailing Address - Fax:703-742-9081
Practice Address - Street 1:1860 TOWN CENTER PKWY
Practice Address - Street 2:#G100 RESTON SURGERY CENTER
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3219
Practice Address - Country:US
Practice Address - Phone:703-471-0919
Practice Address - Fax:703-742-9081
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054984207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
138746OtherANTHEM
G01441F13Medicare ID - Type Unspecified
138746OtherANTHEM
P00157838Medicare ID - Type UnspecifiedRAILROAD