Healthcare Provider Details

I. General information

NPI: 1174934855
Provider Name (Legal Business Name): DUSTIN PARKER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 MADISON AVE SUITE 1031
MEMPHIS TN
38103-3403
US

IV. Provider business mailing address

195 BAKER RD
NEWBERN TN
38059-5403
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-6756
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number3060
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: