Provider Demographics
NPI:1356580468
Name:SPARKLE MEDICAL PA
Entity type:Organization
Organization Name:SPARKLE MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEEMA
Authorized Official - Middle Name:S
Authorized Official - Last Name:RAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-548-8355
Mailing Address - Street 1:1550 PARK AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SO. PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080
Mailing Address - Country:US
Mailing Address - Phone:908-548-8355
Mailing Address - Fax:908-548-8359
Practice Address - Street 1:1550 PARK AVENUE
Practice Address - Street 2:SUIT 104
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080
Practice Address - Country:US
Practice Address - Phone:908-548-8355
Practice Address - Fax:908-548-8359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0220868Medicaid