Provider Demographics
NPI:1215044367
Name:PARKS, JEFFREY D (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:PARKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5342
Mailing Address - Country:US
Mailing Address - Phone:618-767-7023
Mailing Address - Fax:
Practice Address - Street 1:4315 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5342
Practice Address - Country:US
Practice Address - Phone:618-767-7023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062597207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10019630OtherBLUE CROSS
080077375OtherRAILROAD MEDICARE
IL036062597Medicaid
IL143870Medicaid
033308OtherHEALTH ALLIANCE
10019630OtherBLUE CROSS/BLUE SHIELD
103788OtherHEALTHLINK
IL10019630OtherBLUE CROSS
IL036062597Medicaid
IL336570Medicare Oscar/Certification
IL336570Medicare PIN
IL697832Medicare PIN
033308OtherHEALTH ALLIANCE
ILD15096Medicare UPIN