Provider Demographics
NPI:1245214402
Name:PARK, KEN H (MD)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:H
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 1:1624 MARS HILL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-4813
Mailing Address - Country:US
Mailing Address - Phone:706-310-1030
Mailing Address - Fax:706-705-1444
Practice Address - Street 1:1624 MARS HILL RD STE B
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-4813
Practice Address - Country:US
Practice Address - Phone:706-310-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050049207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00904197AMedicaid
GA00904197AMedicaid
GAH46352Medicare UPIN