Basic Information
Provider Information
NPI: 1003801432
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PRATT
FirstName: PARKS
MiddleName: WINFIELD
NamePrefix:  
NameSuffix: III
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4300 W MAIN ST
Address2: SUITE 102
City: DOTHAN
State: AL
PostalCode: 363051054
CountryCode: US
TelephoneNumber: 3347939564
FaxNumber: 3346718907
Practice Location
Address1: 4300 W MAIN ST
Address2: SUITE 102
City: DOTHAN
State: AL
PostalCode: 363051054
CountryCode: US
TelephoneNumber: 3347939564
FaxNumber: 3346718907
Other Information
ProviderEnumerationDate: 09/12/2005
LastUpdateDate: 11/24/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RR0500X14110ALY Allopathic & Osteopathic PhysiciansInternal MedicineRheumatology

ID Information
IDTypeStateIssuerDescription
00008492105AL MEDICAID
00530967A05GA MEDICAID
37214690005FL MEDICAID


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