Provider Demographics
NPI:1780935197
Name:SPARKS, JEFFREY RYAN (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RYAN
Last Name:SPARKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E GRANT ST
Mailing Address - Street 2:SUITE 113
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3368
Mailing Address - Country:US
Mailing Address - Phone:309-833-6937
Mailing Address - Fax:
Practice Address - Street 1:515 E GRANT ST
Practice Address - Street 2:SUITE 113
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3368
Practice Address - Country:US
Practice Address - Phone:309-833-6937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009026507207YX0905X
IL036-132116207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery