Healthcare Provider Details

I. General information

NPI: 1962854471
Provider Name (Legal Business Name): KELLY PARKS DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26520 CACTUS AVE
MORENO VALLEY CA
92555-3927
US

IV. Provider business mailing address

15808 PARRY PEAK DR
FONTANA CA
92336-4642
US

V. Phone/Fax

Practice location:
  • Phone: 951-486-4000
  • Fax:
Mailing address:
  • Phone: 909-910-1989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5531
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberE5531
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE5531
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: