Provider Demographics
NPI:1083690200
Name:PARK, JOHN S (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1255 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE 3900
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6256
Mailing Address - Country:US
Mailing Address - Phone:610-402-1095
Mailing Address - Fax:610-435-5003
Practice Address - Street 1:1255 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 3900
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6256
Practice Address - Country:US
Practice Address - Phone:610-402-1095
Practice Address - Fax:610-435-5003
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2015-03-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD071167L208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH38840Medicare UPIN
NYH38840Medicare UPIN
NY272811Medicare PIN