Provider Demographics
NPI:1124201801
Name:PARK, DANIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
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 1:377 TRAILING PUTT WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5003
Mailing Address - Country:US
Mailing Address - Phone:951-809-5908
Mailing Address - Fax:702-947-5352
Practice Address - Street 1:4270 S DECATUR BLVD STE B6
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-6802
Practice Address - Country:US
Practice Address - Phone:702-485-2100
Practice Address - Fax:702-825-0091
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL05372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry