Provider Demographics
NPI:1083656219
Name:PARK, CONSTANCE MOLINO (MD,PHD)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:MOLINO
Last Name:PARK
Suffix:
Gender:F
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 PARK AVENUE,
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021
Mailing Address - Country:US
Mailing Address - Phone:212-639-9850
Mailing Address - Fax:
Practice Address - Street 1:903 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-0338
Practice Address - Country:US
Practice Address - Phone:212-639-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129822207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C05800Medicare UPIN