Provider Demographics
NPI:1457378028
Name:PARKS, SUSAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:PARKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4414
Mailing Address - Country:US
Mailing Address - Phone:215-955-7190
Mailing Address - Fax:215-955-9186
Practice Address - Street 1:833 CHESTNUT ST
Practice Address - Street 2:SUITE 301
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4414
Practice Address - Country:US
Practice Address - Phone:215-955-7190
Practice Address - Fax:215-955-9186
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-060603-L207Q00000X, 207V00000X
PAMD060603L207QG0300X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0052949Medicaid
PA001719355Medicaid
NJ0052949Medicaid