Provider Demographics
NPI:1689694390
Name:SPARKS, CHARISSE Y (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARISSE
Middle Name:Y
Last Name:SPARKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 W LOOP 281
Mailing Address - Street 2:SUITE 100-131
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-2571
Mailing Address - Country:US
Mailing Address - Phone:816-262-2455
Mailing Address - Fax:
Practice Address - Street 1:1809 W LOOP 281
Practice Address - Street 2:SUITE 100-131
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2571
Practice Address - Country:US
Practice Address - Phone:816-262-2455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO022981207XX0801X
TXP1597207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209342302Medicaid
719498OtherPHP HEALTHLINK
MO10001805100OtherCHP
KS200326080AMedicaid
MO35460011OtherBCBS KANSAS CITY
MO7230075OtherAETNA
MO7230075OtherAETNA
KS200326080AMedicaid
MOP00273060Medicare ID - Type UnspecifiedRR MEDICARE