Provider Demographics
NPI:1295187136
Name:PARK, SAMUEL III (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:PARK
Suffix:III
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 1:401 N MICHIGAN AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4264
Mailing Address - Country:US
Mailing Address - Phone:312-635-0973
Mailing Address - Fax:312-635-0050
Practice Address - Street 1:1240 MCKEE RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-1381
Practice Address - Country:US
Practice Address - Phone:302-672-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-03
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0023852208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation