Provider Demographics
NPI:1023045440
Name:SPARKS, WARREN B (MD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:B
Last Name:SPARKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3791 LOHE RD
Mailing Address - Street 2:
Mailing Address - City:KALAHEO
Mailing Address - State:HI
Mailing Address - Zip Code:96741-9614
Mailing Address - Country:US
Mailing Address - Phone:541-602-0306
Mailing Address - Fax:541-610-1647
Practice Address - Street 1:3791 LOHE RD
Practice Address - Street 2:
Practice Address - City:KALAHEO
Practice Address - State:HI
Practice Address - Zip Code:96741-9614
Practice Address - Country:US
Practice Address - Phone:541-602-0306
Practice Address - Fax:541-610-1647
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4105207P00000X
ORMD15713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA56097OtherL & I
C98636OtherGROUP HEALTH
055542000OtherBCBS
WA8351561Medicaid
OR057237Medicaid
JM9441OtherPACC
8936785OtherCRIME VICTIMS
C98636OtherPROVIDENCE
CAXPY186579Medicaid
WA56097OtherL & I
ORR138488Medicare PIN
C98636Medicare UPIN
OR057237Medicaid