Provider Demographics
NPI:1063866689
Name:PARK, TERRENCE
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 GLEN DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR KNOLLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07927-1316
Mailing Address - Country:US
Mailing Address - Phone:201-916-0735
Mailing Address - Fax:
Practice Address - Street 1:293 MARION AVE # 2
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-2614
Practice Address - Country:US
Practice Address - Phone:201-916-0735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN007212-01213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program