Basic Information
| Provider Information | |||||||||
| NPI: | 1104893775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARKS | ||||||||
| FirstName: | KERRI | ||||||||
| MiddleName: | SHANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1808 VERDUGO BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912081477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189525322 | ||||||||
| FaxNumber: | 8189527993 | ||||||||
| Practice Location | |||||||||
| Address1: | 1808 VERDUGO BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912081477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189525322 | ||||||||
| FaxNumber: | 8189527993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 12/07/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A65496 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0102260 | 05 | CA | MEDICAID |