Provider Demographics
NPI:1205911401
Name:SPARENBERG, CHARLES RUSSELL (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RUSSELL
Last Name:SPARENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3900 W 15TH ST
Mailing Address - Street 2:#106
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-7751
Mailing Address - Country:US
Mailing Address - Phone:972-867-2522
Mailing Address - Fax:972-867-3182
Practice Address - Street 1:3900 W 15TH ST
Practice Address - Street 2:#106
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7751
Practice Address - Country:US
Practice Address - Phone:972-867-2522
Practice Address - Fax:972-867-3182
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC9674208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00H98FMedicare PIN
B26594Medicare UPIN
TXTXB145122Medicare PIN