Provider Demographics
NPI:1114928801
Name:PARK, KENNETH WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:PARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CARLISLE CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-1908
Mailing Address - Country:US
Mailing Address - Phone:847-639-1685
Mailing Address - Fax:
Practice Address - Street 1:125 CARLISLE CT
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-1908
Practice Address - Country:US
Practice Address - Phone:847-639-1685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE34324Medicare UPIN
IL208630Medicare ID - Type UnspecifiedMEDICARE PART B PROVIDER