Provider Demographics
NPI:1811444235
Name:PARKER, GWENDOLYN HENDERSON (MD)
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:HENDERSON
Last Name:PARKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:600 E. LAFAYETTE BLVD
Mailing Address - Street 2:MC 504D C/O BCBSM
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-2998
Mailing Address - Country:US
Mailing Address - Phone:313-448-6780
Mailing Address - Fax:866-648-5525
Practice Address - Street 1:48165 LIBERTY DR
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48315-4061
Practice Address - Country:US
Practice Address - Phone:313-448-6780
Practice Address - Fax:866-648-5525
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43014054082085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology