Provider Demographics
NPI:1811588593
Name:PARKER, KENNETH (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:PARKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 NW 57TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-6415
Mailing Address - Country:US
Mailing Address - Phone:352-331-7771
Mailing Address - Fax:352-331-7771
Practice Address - Street 1:832 NW 57TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-6415
Practice Address - Country:US
Practice Address - Phone:352-331-7771
Practice Address - Fax:352-331-4302
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOPC6008152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program