Provider Demographics
NPI:1376717215
Name:DR. DAVID J. PARKER, JR.
Entity Type:Organization
Organization Name:DR. DAVID J. PARKER, JR.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JASPER
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:662-746-1623
Mailing Address - Street 1:PO BOX 202
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-0202
Mailing Address - Country:US
Mailing Address - Phone:662-746-1623
Mailing Address - Fax:662-746-4397
Practice Address - Street 1:110 N JERRY CLOWER BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-8669
Practice Address - Country:US
Practice Address - Phone:662-746-1623
Practice Address - Fax:662-746-4397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS534152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087095Medicaid
MS410000013Medicare PIN
MST21164Medicare UPIN
MS00087095Medicaid