Provider Demographics
NPI:1811963457
Name:PARKER, RUSSELL KENNETH (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:KENNETH
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 1:1613 BAYITA LN NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3320
Mailing Address - Country:US
Mailing Address - Phone:505-269-4669
Mailing Address - Fax:
Practice Address - Street 1:1613 BAYITA LN NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-3320
Practice Address - Country:US
Practice Address - Phone:505-269-4669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM992772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ6244Medicaid
NMZ6244Medicaid
AZ528896Medicaid