Provider Demographics
NPI:1033393319
Name:SPARKS, LOWERY H (OD)
Entity Type:Individual
Prefix:DR
First Name:LOWERY
Middle Name:H
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 1:15017 EMERALD COAST PKWY
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3358
Mailing Address - Country:US
Mailing Address - Phone:850-650-0356
Mailing Address - Fax:
Practice Address - Street 1:15017 EMERALD COAST PKWY
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-3358
Practice Address - Country:US
Practice Address - Phone:850-650-0356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-23
Last Update Date:2007-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 003285152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20907Medicare PIN