Provider Demographics
NPI:1780651711
Name:PARKER, MARYLYNN W (MD)
Entity Type:Individual
Prefix:
First Name:MARYLYNN
Middle Name:W
Last Name:PARKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1289
Mailing Address - Country:US
Mailing Address - Phone:334-793-6556
Mailing Address - Fax:334-793-0977
Practice Address - Street 1:2115 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1289
Practice Address - Country:US
Practice Address - Phone:334-793-6556
Practice Address - Fax:334-793-0977
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00018385207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALF59518Medicare UPIN
AL051033583Medicare ID - Type Unspecified