Provider Demographics
NPI:1043288459
Name:PARKER, ROBERTA JEAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:JEAN
Last Name:PARKER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 WEST LANIER AVENUE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:770-460-5064
Mailing Address - Fax:770-460-0838
Practice Address - Street 1:730 WEST LANIER AVENUE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-460-5064
Practice Address - Fax:770-460-0838
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA000588213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00456244AMedicaid
T89056Medicare UPIN
GA485CBFHMedicare ID - Type Unspecified