Provider Demographics
NPI:1114293487
Name:PARK, TED S (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:TED
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 K ST NW STE 2
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-1810
Mailing Address - Country:US
Mailing Address - Phone:202-785-8704
Mailing Address - Fax:202-464-0039
Practice Address - Street 1:2141 K ST NW STE 2
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-1810
Practice Address - Country:US
Practice Address - Phone:202-785-8704
Practice Address - Fax:202-464-0039
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02077237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist