Provider Demographics
NPI:1831201144
Name:SPARKS, RANDAL P (DO)
Entity type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:P
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 1:600 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:OLIVIA
Mailing Address - State:MN
Mailing Address - Zip Code:56277-1370
Mailing Address - Country:US
Mailing Address - Phone:320-523-1460
Mailing Address - Fax:320-523-1703
Practice Address - Street 1:600 EAST FAIRVIEW AVENUE
Practice Address - Street 2:
Practice Address - City:OLIVIA
Practice Address - State:MN
Practice Address - Zip Code:56277-1399
Practice Address - Country:US
Practice Address - Phone:320-523-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-437207Q00000X
MN52538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51028285OtherBLUE CROSS BLUE SHIELD
AL529402090Medicaid
6309683290010OtherCIGNA
0110005OtherUNITED HEALTHCARE
0004119242OtherAETNA
6309683290010OtherCIGNA
0110005OtherUNITED HEALTHCARE
0004119242OtherAETNA