Provider Demographics
NPI:1144239740
Name:PARK, BENJAMIN (MD)
Entity Type:Individual
Prefix:
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 1:194 MISSILE AVE
Mailing Address - Street 2:
Mailing Address - City:MINOT AFB
Mailing Address - State:ND
Mailing Address - Zip Code:58705
Mailing Address - Country:US
Mailing Address - Phone:701-723-5100
Mailing Address - Fax:
Practice Address - Street 1:194 MISSILE AVE
Practice Address - Street 2:
Practice Address - City:MINOT AFB
Practice Address - State:ND
Practice Address - Zip Code:58705
Practice Address - Country:US
Practice Address - Phone:701-723-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062522A207Q00000X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine