Provider Demographics
NPI:1598790263
Name:SPARKS, KENNETH O (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:O
Last Name:SPARKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8383 WILSHIRE BLVD STE 440
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2436
Mailing Address - Country:US
Mailing Address - Phone:323-655-8036
Mailing Address - Fax:323-655-8443
Practice Address - Street 1:8383 WILSHIRE BLVD
Practice Address - Street 2:SUITE 440
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2425
Practice Address - Country:US
Practice Address - Phone:323-655-8036
Practice Address - Fax:323-655-8443
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39756207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G397560Medicaid
CA00G397560Medicaid
CAA479471Medicare UPIN