Provider Demographics
NPI:1013057488
Name:SPARKS, JAY L (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:L
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:3231 S NATIONAL AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-820-7450
Practice Address - Fax:417-820-7455
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104280207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154945001Medicaid
MO208134619Medicaid
AR98450OtherARK BLUE SHIELD
MO126737OtherMO BLUE SHIELD
MO310593230Medicare PIN
MO208134619Medicaid
MO210013268Medicare PIN