Healthcare Provider Details

I. General information

NPI: 1952394751
Provider Name (Legal Business Name): JOHNNY DAN PARKER D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 S COTTAGE GROVE AVE
CHICAGO IL
60619-6107
US

IV. Provider business mailing address

8601 S COTTAGE GROVE AVE
CHICAGO IL
60619-6107
US

V. Phone/Fax

Practice location:
  • Phone: 773-783-7599
  • Fax: 773-783-7698
Mailing address:
  • Phone: 773-783-7599
  • Fax: 773-783-7698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: