Provider Demographics
NPI:1700901915
Name:PARKER, BRENT A (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:A
Last Name:PARKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5165 MCCARTY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8764
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-838-4758
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01090848A207L00000X
TXM2741207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN815500693OtherMEDICARE PTAN
IN1103150970OtherANTHEM PTAN
IN264430I12OtherMEDICARE PTAN
INQ00572843OtherRAILROAD PTAN
TX0004PHOtherBLUE SHIELD
IN300081598Medicaid