Provider Demographics
NPI:1265418537
Name:SPARKS, ESTEL RAY (OD)
Entity type:Individual
Prefix:
First Name:ESTEL
Middle Name:RAY
Last Name:SPARKS
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 1:3321 WARPATH DR
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38572-6639
Mailing Address - Country:US
Mailing Address - Phone:931-788-6498
Mailing Address - Fax:
Practice Address - Street 1:473 FRONT ST
Practice Address - Street 2:
Practice Address - City:SPRING CITY
Practice Address - State:TN
Practice Address - Zip Code:37381-5198
Practice Address - Country:US
Practice Address - Phone:423-365-4313
Practice Address - Fax:423-365-4413
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1123152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T81678Medicare UPIN
TN3596780Medicare ID - Type Unspecified