Provider Demographics
NPI:1124551239
Name:PARK, SAMUEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:S
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:PO BOX 4069
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-0007
Mailing Address - Country:US
Mailing Address - Phone:206-543-2470
Mailing Address - Fax:
Practice Address - Street 1:12040 NE 128TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:425-899-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61147982207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology