Provider Demographics
NPI:1962854471
Name:PARKS, KELLY (DPM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PARKS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15808 PARRY PEAK DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4642
Mailing Address - Country:US
Mailing Address - Phone:909-910-1989
Mailing Address - Fax:
Practice Address - Street 1:795 E 2ND ST STE 7
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-2007
Practice Address - Country:US
Practice Address - Phone:909-706-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5531213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery