Provider Demographics
NPI:1104893775
Name:PARKS, KERRI SHANE (MD)
Entity type:Individual
Prefix:DR
First Name:KERRI
Middle Name:SHANE
Last Name:PARKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 VERDUGO BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1477
Mailing Address - Country:US
Mailing Address - Phone:818-952-5322
Mailing Address - Fax:818-952-7993
Practice Address - Street 1:1808 VERDUGO BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1477
Practice Address - Country:US
Practice Address - Phone:818-952-5322
Practice Address - Fax:818-952-7993
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65496174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102260Medicaid
CAGR0102260Medicaid
CAH31405Medicare UPIN