Provider Demographics
NPI:1265481519
Name:PARK, DAVID Y (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:Y
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 1:330 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-9470
Mailing Address - Country:US
Mailing Address - Phone:541-997-2820
Mailing Address - Fax:541-997-7197
Practice Address - Street 1:330 9TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-9470
Practice Address - Country:US
Practice Address - Phone:541-902-6140
Practice Address - Fax:541-902-7533
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25431208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD25431OtherSTATE LICENSE
ORR120791Medicare PIN
ORMD25431OtherSTATE LICENSE