Provider Demographics
NPI:1356324404
Name:PARK, DUK J (MD)
Entity Type:Individual
Prefix:DR
First Name:DUK
Middle Name:J
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:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-0039
Mailing Address - Country:US
Mailing Address - Phone:636-937-9322
Mailing Address - Fax:636-937-4590
Practice Address - Street 1:166 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4133
Practice Address - Country:US
Practice Address - Phone:636-937-9322
Practice Address - Fax:636-937-4590
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200393304Medicaid
MO000003479Medicare PIN
MO200393304Medicaid