Provider Demographics
NPI:1245203512
Name:PARKS, CLARENCE A (MD)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:A
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 1:1645 W JACKSON BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3276
Mailing Address - Country:US
Mailing Address - Phone:312-942-6800
Mailing Address - Fax:312-942-3551
Practice Address - Street 1:1645 W JACKSON BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3276
Practice Address - Country:US
Practice Address - Phone:312-942-6800
Practice Address - Fax:312-942-3551
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105357207R00000X
IL036-105357208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105351Medicaid
IL036105351Medicaid
ILH47045Medicare UPIN