Provider Demographics
NPI:1073737763
Name:PARKER, AUDRA JUSTINE (MD)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:JUSTINE
Last Name:PARKER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8050 E MAIN ST STE 2200
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2652
Mailing Address - Country:US
Mailing Address - Phone:614-864-6010
Mailing Address - Fax:614-864-0306
Practice Address - Street 1:8050 E MAIN ST STE 2200
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2652
Practice Address - Country:US
Practice Address - Phone:614-864-6010
Practice Address - Fax:614-864-0306
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.089458207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2767779Medicaid
OH2767779Medicaid