Basic Information
| Provider Information | |||||||||
| NPI: | 1447251277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARKS | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 BOSTON AVENUE | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324704798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077757654 | ||||||||
| FaxNumber: | 4078376082 | ||||||||
| Practice Location | |||||||||
| Address1: | 2225 NORTH CENTRAL AVENUE | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347412342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079332908 | ||||||||
| FaxNumber: | 4078461657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 05/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME66619 | FL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 376066900 | 05 | FL | MEDICAID | BP1564827 | 01 | FL | DEA | OTHER |