Healthcare Provider Details

I. General information

NPI: 1669886537
Provider Name (Legal Business Name): JACOB PARKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 WILES RD STE 201
COCONUT CREEK FL
33073-3414
US

IV. Provider business mailing address

4515 WILES RD STE 201
COCONUT CREEK FL
33073-3414
US

V. Phone/Fax

Practice location:
  • Phone: 954-943-1133
  • Fax: 954-783-6845
Mailing address:
  • Phone: 954-943-1133
  • Fax: 954-783-6845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301105492
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2019024767
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME154933
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: