Provider Demographics
NPI:1770533507
Name:SPARKS, GERALD ANTHONY JR (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:ANTHONY
Last Name:SPARKS
Suffix:JR
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 1:1903 HAND AVE
Mailing Address - Street 2:
Mailing Address - City:BAY MINETTE
Mailing Address - State:AL
Mailing Address - Zip Code:36507-4112
Mailing Address - Country:US
Mailing Address - Phone:251-937-7970
Mailing Address - Fax:251-937-9260
Practice Address - Street 1:1903 HAND AVE
Practice Address - Street 2:
Practice Address - City:BAY MINETTE
Practice Address - State:AL
Practice Address - Zip Code:36507-4112
Practice Address - Country:US
Practice Address - Phone:251-937-7970
Practice Address - Fax:251-937-9260
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21976207P00000X
AL00021976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
510-03800OtherBCBS
AL009996010Medicaid
AL1770533507OtherTRICARE SOUTH
AL51510991OtherBCBS
AL009936961Medicaid
AL009936961Medicaid
P00332706Medicare PIN
AL009996010Medicaid
ALG99652Medicare UPIN