Provider Demographics
NPI:1194112870
Name:SPARKS, BLAKE BUTLER (MD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:BUTLER
Last Name:SPARKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 WATERWORKS WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3174
Mailing Address - Country:US
Mailing Address - Phone:949-653-7000
Mailing Address - Fax:
Practice Address - Street 1:113 WATERWORKS WAY STE 300
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3174
Practice Address - Country:US
Practice Address - Phone:949-653-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY55738208200000X
CAA204050208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery