Provider Demographics
NPI:1740361476
Name:PARKE, JOHN S (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:PARKE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:S
Other - Last Name:PARKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:1438 LAKESHORE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-1644
Mailing Address - Country:US
Mailing Address - Phone:510-282-8089
Mailing Address - Fax:510-465-2537
Practice Address - Street 1:1053 ALAMEDA DE LAS PULGAS
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-3507
Practice Address - Country:US
Practice Address - Phone:510-282-8089
Practice Address - Fax:510-465-2537
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18990103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL189900Medicare PIN
CAP96398Medicare UPIN