Provider Demographics
NPI:1083617633
Name:PARK, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
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 1:2111 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3329
Mailing Address - Country:US
Mailing Address - Phone:503-325-4321
Mailing Address - Fax:
Practice Address - Street 1:2265 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3331
Practice Address - Country:US
Practice Address - Phone:503-338-7595
Practice Address - Fax:503-325-4905
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26448207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240068OtherDMAP/OMAP
CA00A639530Medicare ID - Type Unspecified
OR240068OtherDMAP/OMAP