Provider Demographics
NPI:1609914902
Name:PARKER, WAYLON MORRIS (MD)
Entity Type:Individual
Prefix:
First Name:WAYLON
Middle Name:MORRIS
Last Name:PARKER
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 1:5635 MAIN STREET
Mailing Address - Street 2:SUITE A #222
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791
Mailing Address - Country:US
Mailing Address - Phone:225-634-4079
Mailing Address - Fax:
Practice Address - Street 1:5002 HIGHWAY 10
Practice Address - Street 2:VILLA FELICIANA MEDICAL COMPLEX
Practice Address - City:JACKSON
Practice Address - State:LA
Practice Address - Zip Code:70748
Practice Address - Country:US
Practice Address - Phone:225-634-4079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016672208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
E76944Medicare UPIN