Provider Demographics
NPI:1942483375
Name:KERRI S. PARKS, M. D., A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KERRI S. PARKS, M. D., A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-952-5322
Mailing Address - Street 1:1808 VERDUGO BLVD
Mailing Address - Street 2:#208
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1477
Mailing Address - Country:US
Mailing Address - Phone:818-952-5322
Mailing Address - Fax:818-952-7993
Practice Address - Street 1:1808 VERDUGO BLVD
Practice Address - Street 2:#208
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1477
Practice Address - Country:US
Practice Address - Phone:818-952-5322
Practice Address - Fax:818-952-7993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102260Medicaid
CAGR0102260Medicaid
CAI42379Medicare UPIN
CAW19233Medicare PIN
CAWA79900AMedicare PIN
CAWA91183Medicare PIN
CAWA65496DMedicare PIN
CAH82072Medicare UPIN