Provider Demographics
NPI:1073737763
Name:PARKER, AUDRA JUSTINE (MD)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:JUSTINE
Last Name:PARKER
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 1:6069 E MAIN ST STE 112
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-4302
Mailing Address - Country:US
Mailing Address - Phone:614-755-3000
Mailing Address - Fax:614-755-4052
Practice Address - Street 1:6069 E MAIN ST STE 112
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-4302
Practice Address - Country:US
Practice Address - Phone:614-755-3000
Practice Address - Fax:614-755-4052
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.089458207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2767779Medicaid
OH2767779Medicaid