Healthcare Provider Details

I. General information

NPI: 1942528518
Provider Name (Legal Business Name): JOHN TICE PARKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3924 MINNESOTA AVE. NE UNITY HEALTHCARE - MINNESOTA AVENUE CLINIC
WASHINGTON DC
20019
US

IV. Provider business mailing address

3924 MINNESOTA AVE. NE UNITY HEALTHCARE - MINNESOTA AVENUE CLINIC
WASHINGTON DC
20019
US

V. Phone/Fax

Practice location:
  • Phone: 202-398-8683
  • Fax: 202-627-7815
Mailing address:
  • Phone: 202-398-8683
  • Fax: 202-627-7815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD041594
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number164607
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: