Provider Demographics
NPI:1174723332
Name:SPARKS, KRISTAN C (OD)
Entity type:Individual
Prefix:DR
First Name:KRISTAN
Middle Name:C
Last Name:SPARKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-0547
Mailing Address - Country:US
Mailing Address - Phone:208-357-5733
Mailing Address - Fax:208-357-2240
Practice Address - Street 1:169 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1226
Practice Address - Country:US
Practice Address - Phone:208-357-5733
Practice Address - Fax:208-357-2240
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP638152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID21776OtherSPECTERA
IDV5988OtherBLUE CROSS
ID90638OtherVBA
ID001251300Medicaid
ID000010015251OtherBLUE SHIELD
ID1591226Medicare Oscar/Certification