Provider Demographics
NPI:1336134360
Name:PARKS, JEFFREY DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DEAN
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 1:400 LAKEBRIDGE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5157
Mailing Address - Country:US
Mailing Address - Phone:386-677-9044
Mailing Address - Fax:386-677-3083
Practice Address - Street 1:400 LAKEBRIDGE PLAZA DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5157
Practice Address - Country:US
Practice Address - Phone:386-677-9044
Practice Address - Fax:386-677-3083
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67417207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG45925Medicare UPIN
FL32804ZMedicare ID - Type Unspecified