Provider Demographics
NPI:1033219563
Name:PARK, JANELLE LIRA (MD)
Entity Type:Individual
Prefix:DR
First Name:JANELLE
Middle Name:LIRA
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 COURT ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-1729
Mailing Address - Country:US
Mailing Address - Phone:603-354-5400
Mailing Address - Fax:
Practice Address - Street 1:580 COURT ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-1729
Practice Address - Country:US
Practice Address - Phone:603-354-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA788312085R0001X
FLME1038162085R0001X
NH232002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00811542OtherRR MEDICARE
FL001497200Medicaid
FL146KHOtherBCBS
FL331658OtherAVMED
FL331658OtherAVMED
FLCM999ZMedicare PIN
FLCM999VMedicare PIN
FLP00811542OtherRR MEDICARE
FLCM999WMedicare PIN
FL21682JMedicare PIN
FL001497200Medicaid
FLCM999XMedicare PIN