MEDICARE: KENNETH O SPARKS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	G39756	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598790263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH O SPARKS M.D.

Provider Business Mailing Address
First Line	:	8383 WILSHIRE BLVD STE 440
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-2436
Country	:	US
Telephone Number	:	323-655-8036
Fax Number	:	323-655-8443

Provider Business Practice Location Address
First Line	:	8383 WILSHIRE BLVD
Second Line	:	SUITE 440
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-2425
Country	:	US
Telephone Number	:	323-655-8036
Fax Number	:	323-655-8443

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	06/18/2020

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