Provider Demographics
NPI:1427443613
Name:SPARKMD
Entity type:Organization
Organization Name:SPARKMD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:KRISTEN
Authorized Official - Last Name:GUNTHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FAAFP
Authorized Official - Phone:208-369-4590
Mailing Address - Street 1:302 W IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6039
Mailing Address - Country:US
Mailing Address - Phone:208-369-4590
Mailing Address - Fax:
Practice Address - Street 1:302 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6039
Practice Address - Country:US
Practice Address - Phone:208-369-4590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10803261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care