Provider Demographics
NPI:1306820451
Name:DOUGLAS PARK I, LTD
Entity Type:Organization
Organization Name:DOUGLAS PARK I, LTD
Other - Org Name:ODESSA KIDNEY DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-687-4044
Mailing Address - Street 1:6005 EASTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-5019
Mailing Address - Country:US
Mailing Address - Phone:432-550-6012
Mailing Address - Fax:432-550-7201
Practice Address - Street 1:6005 EASTRIDGE RD
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5019
Practice Address - Country:US
Practice Address - Phone:432-550-6012
Practice Address - Fax:432-550-7201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008017261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH7000OtherBC/BS
TXHH7000OtherBC/BS