Provider Demographics
NPI:1548467194
Name:KEITH B SPARKMAN
Entity type:Organization
Organization Name:KEITH B SPARKMAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:B
Authorized Official - Last Name:SPARKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-855-8288
Mailing Address - Street 1:1013 SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37412-3971
Mailing Address - Country:US
Mailing Address - Phone:423-855-8288
Mailing Address - Fax:423-855-4527
Practice Address - Street 1:1013 SPRING CREEK RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37412-3971
Practice Address - Country:US
Practice Address - Phone:423-855-8288
Practice Address - Fax:423-855-4527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3599732OtherMEDICAID
TN2240306OtherUNITED HEALTH
TN3088639OtherBLUE CROSS BLUE SHIELD
TN6005850001Medicare NSC
TN3942400Medicare ID - Type Unspecified
TN410040394Medicare ID - Type UnspecifiedRAILROAD