Provider Demographics
NPI:1982603346
Name:PARKER, JEFFREY A (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:PARKER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-1808
Mailing Address - Country:US
Mailing Address - Phone:845-856-7700
Mailing Address - Fax:845-858-9284
Practice Address - Street 1:156 PIKE ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-1808
Practice Address - Country:US
Practice Address - Phone:845-856-7700
Practice Address - Fax:845-858-9284
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN002727-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01537044Medicaid
NY01537044Medicaid
T50850Medicare UPIN