Provider Demographics
NPI:1629063680
Name:PARKS DERMATOLOGY CENTER LLC
Entity Type:Organization
Organization Name:PARKS DERMATOLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-677-9044
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0993Medicare ID - Type Unspecified