Provider Demographics
NPI:1124393558
Name:PARK, BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 CLIFTON RD NE # MSC09
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4018
Mailing Address - Country:US
Mailing Address - Phone:404-639-1619
Mailing Address - Fax:404-639-0070
Practice Address - Street 1:1600 CLIFTON RD NE # MSC09
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4018
Practice Address - Country:US
Practice Address - Phone:404-639-1619
Practice Address - Fax:404-639-0070
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58091207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine