Provider Demographics
NPI:1043659956
Name:PARK, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:PARK
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 1:4811 WOODROW AVE UNIT 202
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-5803
Mailing Address - Country:US
Mailing Address - Phone:347-226-8009
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:347-226-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY286449207R00000X, 208M00000X
IN01078485A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine