Provider Demographics
NPI:1073699120
Name:PARK, EDYTHE B (MD)
Entity Type:Individual
Prefix:MRS
First Name:EDYTHE
Middle Name:B
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 1:2725 S.E. MARICAMP ROAD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471
Mailing Address - Country:US
Mailing Address - Phone:352-369-8700
Mailing Address - Fax:352-369-8703
Practice Address - Street 1:2725 SE MARICAMP RD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-5537
Practice Address - Country:US
Practice Address - Phone:352-369-8700
Practice Address - Fax:352-369-8703
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100186208000000X
173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME100186OtherSTATE LICENSE
FLME100186OtherSTATE LICENSE