Healthcare Provider Details

I. General information

NPI: 1558564591
Provider Name (Legal Business Name): JOSEPH WILLIAM PARKS IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 OLD SAINT AUGUSTINE RD STE 2391 SUITE C50
JACKSONVILLE FL
32258-7418
US

IV. Provider business mailing address

11945 SAN JOSE BLVD STE 300
JACKSONVILLE FL
32223-1627
US

V. Phone/Fax

Practice location:
  • Phone: 904-262-3372
  • Fax: 904-262-3306
Mailing address:
  • Phone: 904-396-1725
  • Fax: 904-399-1717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME 116390
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: