Provider Demographics
NPI:1467499475
Name:PARKS, KEVIN WILSON (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILSON
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 1:3860 CRATER LAKE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9741
Mailing Address - Country:US
Mailing Address - Phone:541-858-1003
Mailing Address - Fax:541-857-4499
Practice Address - Street 1:3860 CRATER LAKE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9741
Practice Address - Country:US
Practice Address - Phone:541-858-1003
Practice Address - Fax:541-857-4499
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26375207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR120824Medicare UPIN
OR137734Medicare PIN