Provider Demographics
NPI:1093729477
Name:PARKS, DALE GENE (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:GENE
Last Name:PARKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4560 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 303
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292
Mailing Address - Country:US
Mailing Address - Phone:310-822-5066
Mailing Address - Fax:310-827-4420
Practice Address - Street 1:12555 W JEFFERSON BLVD STE 303
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-7032
Practice Address - Country:US
Practice Address - Phone:310-822-5066
Practice Address - Fax:310-827-4420
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC35271207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C352710Medicaid
CAW3056Medicare ID - Type Unspecified
CA00C352710Medicaid