Provider Demographics
NPI:1144757162
Name:PARK, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 NW 14TH TER FL 2
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1060
Mailing Address - Country:US
Mailing Address - Phone:305-243-6946
Mailing Address - Fax:305-243-3337
Practice Address - Street 1:1095 NW 14TH TER FL 2
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1060
Practice Address - Country:US
Practice Address - Phone:305-243-6946
Practice Address - Fax:305-243-3337
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME166767207T00000X
IAR-10869207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery