Healthcare Provider Details

I. General information

NPI: 1780940403
Provider Name (Legal Business Name): BRIAN KEITH SPARKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9155 SW BARNES RD STE 333
PORTLAND OR
97225-6630
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-216-5102
  • Fax: 971-282-0091
Mailing address:
  • Phone: 503-215-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD190671
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA142587
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberA142587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: