Healthcare Provider Details

I. General information

NPI: 1609218023
Provider Name (Legal Business Name): TANAYA SPARKLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2013
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BUENA VISTA ST
BURBANK CA
91505-4809
US

IV. Provider business mailing address

12105 FALCON CREST WAY
PORTER RANCH CA
91326-3896
US

V. Phone/Fax

Practice location:
  • Phone: 773-875-5610
  • Fax:
Mailing address:
  • Phone: 773-875-5610
  • Fax: 773-875-5610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35.133371
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC196215
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: