Provider Demographics
NPI:1285798405
Name:PARKER, RONALD DALE (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:DALE
Last Name:PARKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 S KOFA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-6477
Mailing Address - Country:US
Mailing Address - Phone:928-669-9700
Mailing Address - Fax:928-669-9104
Practice Address - Street 1:1713 S KOFA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-6477
Practice Address - Country:US
Practice Address - Phone:928-669-9700
Practice Address - Fax:928-669-9104
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36577207Q00000X
NV11353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVI32796Medicare UPIN
NV100956Medicare ID - Type UnspecifiedPROVIDER MEDICARE NUMBER