Basic Information
Provider Information | |||||||||
NPI: | 1831192830 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARKS | ||||||||
FirstName: | CLARA | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PARKS | ||||||||
OtherFirstName: | LEE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.O. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1800 COMMUNITY | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MO | ||||||||
PostalCode: | 647358804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608858131 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1780 OLD HIGHWAY 50 E | ||||||||
Address2: |   | ||||||||
City: | UNION | ||||||||
State: | MO | ||||||||
PostalCode: | 630843397 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8448538937 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2005 | ||||||||
LastUpdateDate: | 03/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R7F01 | MO | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | PA242466720 | 05 | MO |   | MEDICAID | 1850 | 01 | MO | HEALTHCAREUSA | OTHER |