Provider Demographics
NPI:1700949989
Name:SPARKMAN, KEITH BRIAN (OD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:BRIAN
Last Name:SPARKMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37412
Mailing Address - Country:US
Mailing Address - Phone:423-855-8288
Mailing Address - Fax:423-855-4527
Practice Address - Street 1:1013 SPRING CREEK RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37412
Practice Address - Country:US
Practice Address - Phone:423-855-8288
Practice Address - Fax:423-855-4527
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1603152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2240306OtherUNITED HEALTH
3088639OtherBLUE CROSS BLUE SHIELD
410040394OtherMEDICARE RAILROAD
TN3599732Medicaid
410040394OtherMEDICARE RAILROAD
TN3599732Medicaid
TN6005850001Medicare NSC