Provider Demographics
NPI:1609928993
Name:SPARKMAN, KRISTIE MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIE
Middle Name:MICHELLE
Last Name:SPARKMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KRISTIE
Other - Middle Name:MICHELLE
Other - Last Name:HOMUTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:9404 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2421
Mailing Address - Country:US
Mailing Address - Phone:909-482-0369
Mailing Address - Fax:909-482-0758
Practice Address - Street 1:9404 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2421
Practice Address - Country:US
Practice Address - Phone:909-482-0369
Practice Address - Fax:909-482-0758
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 10623 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist