Provider Demographics
NPI:1831204130
Name:PARKER, JERRY MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:MICHAEL
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 1:1001 PACIFIC STREET
Mailing Address - Street 2:
Mailing Address - City:MONTERY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-4453
Mailing Address - Country:US
Mailing Address - Phone:831-373-4363
Mailing Address - Fax:831-373-6457
Practice Address - Street 1:1001 PACIFIC STREET
Practice Address - Street 2:
Practice Address - City:MONTERY
Practice Address - State:CA
Practice Address - Zip Code:93940-4453
Practice Address - Country:US
Practice Address - Phone:831-373-4363
Practice Address - Fax:831-373-6457
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG8322208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA902609983OtherTRICARE
CA942609983OtherBLUE CROSS
CA942609983OtherTRICARE TRIWEST
CA000G83220OtherBLUE SHIELD
CA000G83220Medicaid
CA000G83220OtherBLUE SHIELD
CA942609983OtherBLUE CROSS