Provider Demographics
NPI:1700850500
Name:PARKER, DERRALL SHAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRALL
Middle Name:SHAWN
Last Name:PARKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:D. SHAWN
Other - Middle Name:
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:360 S MOUNT AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4920
Mailing Address - Country:US
Mailing Address - Phone:573-335-3577
Mailing Address - Fax:573-335-1559
Practice Address - Street 1:360 S MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4920
Practice Address - Country:US
Practice Address - Phone:573-335-3577
Practice Address - Fax:573-335-1559
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY30522207W00000X
MOMD116562207W00000X
MO036-101500207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO115309OtherBC BS MO 43.1804777
MO1238355OtherFIRST HEALTH 43.1804777
MO180035388OtherRAILROAD CARE 43.1804777
KY5971604OtherAETNA 61.1257991
KY180042674OtherRAILROAD CARE 61.1257991
KY393192OtherHEALTHLINK 61.1257991
ILP00288000OtherRAILROAD CARE 43.1804777
KY180035389OtherRAILROAD CARE 43.1804777
MO205249600Medicaid
KY000000112968OtherBC BS TAX ID 61.1257991
KY64012115Medicaid
MO393192OtherHEALTHLINK 43.1804777
KYG48960OtherBLUEGRASS FAM 61.1257991
KYG48960OtherBLUEGRASS FAM 61.1257991
MO205249600Medicaid
MO115309OtherBC BS MO 43.1804777
KY000000112968OtherBC BS TAX ID 61.1257991
KY180035389OtherRAILROAD CARE 43.1804777
ILP00288000OtherRAILROAD CARE 43.1804777