Provider Demographics
NPI:1205183514
Name:PARK, DANIEL (LIC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:LIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 MEADOWVIEW CT
Mailing Address - Street 2:
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-2043
Mailing Address - Country:US
Mailing Address - Phone:201-315-8787
Mailing Address - Fax:
Practice Address - Street 1:277 CLOSTER DOCK RD
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-2445
Practice Address - Country:US
Practice Address - Phone:973-777-7040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00081800171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist