Healthcare Provider Details

I. General information

NPI: 1912937475
Provider Name (Legal Business Name): MARK PARKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 CAMERON VALLEY PKWY SUITE 200
CHARLOTTE NC
28211-4297
US

IV. Provider business mailing address

4501 CAMERON VALLEY PKWY
CHARLOTTE NC
28211-4297
US

V. Phone/Fax

Practice location:
  • Phone: 704-512-3636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number32413
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberMD2019-0007
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: