Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 38MC00268900 | NJ |
NPI | 1275667537 |
---|---|
Provider Name | Dr. Kevin Parks |
First Address | Wall, NJ 07719-3764 |
Second Address | Wall, NJ 07719-3764 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T45456 | (02) | NJ |