Provider Demographics
NPI:1326292640
Name:SPARKS, STEPHEN T (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:T
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 1:14375 NASON ST.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4727
Mailing Address - Country:US
Mailing Address - Phone:951-486-5984
Mailing Address - Fax:951-486-4295
Practice Address - Street 1:14375 NASON ST.
Practice Address - Street 2:SUITE 101
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4727
Practice Address - Country:US
Practice Address - Phone:951-486-5984
Practice Address - Fax:951-486-4295
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG567852083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C04315Medicare UPIN