Healthcare Provider Details

I. General information

NPI: 1114244159
Provider Name (Legal Business Name): SUSAN WELLS PARKS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2010
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS WAY SLOT 512-19A
LITTLE ROCK AR
72202-3500
US

IV. Provider business mailing address

101 SIVLEY RD SW
HUNTSVILLE AL
35801-4421
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-1100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.35290
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: