Provider Demographics
NPI:1306858790
Name:PARK, DAVID J (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 AMERICAN PACIFIC DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-8800
Mailing Address - Country:US
Mailing Address - Phone:702-777-4809
Mailing Address - Fax:
Practice Address - Street 1:874 AMERICAN PACIFIC DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-8800
Practice Address - Country:US
Practice Address - Phone:702-777-1772
Practice Address - Fax:702-777-4828
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1266207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1306858790Medicaid
NVBV625UMedicare PIN
NVBV625VMedicare PIN
NV1306858790Medicaid
NV102771Medicare PIN
NVBV 625ZMedicare PIN