Provider Demographics
NPI:1922162007
Name:PARKER, DAVID J JR
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:PARKER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 202
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-0202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 N JERRY CLOWER BLVD
Practice Address - Street 2:STE H
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-8669
Practice Address - Country:US
Practice Address - Phone:662-746-1623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS534152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087095Medicaid
T21164Medicare UPIN
MS410000013Medicare PIN
MS00087095Medicaid