Provider Demographics
NPI:1225792591
Name:PARK, DAVID SPRING (LAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:SPRING
Last Name:PARK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 CLAREMONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6331
Mailing Address - Country:US
Mailing Address - Phone:201-625-5471
Mailing Address - Fax:
Practice Address - Street 1:52 CLAREMONT RD
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6331
Practice Address - Country:US
Practice Address - Phone:201-625-5471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-23
Last Update Date:2021-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00154100171100000X
NY006894171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist