Provider Demographics
NPI:1376533943
Name:PARK, MICHELLE M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3905
Mailing Address - Country:US
Mailing Address - Phone:602-241-1944
Mailing Address - Fax:602-241-1917
Practice Address - Street 1:3410 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3905
Practice Address - Country:US
Practice Address - Phone:602-241-1944
Practice Address - Fax:602-241-1917
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29441207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ694697Medicaid
AZAZ0155910OtherBCBS OF AZ
AZ104635Medicare ID - Type Unspecified
AZ694697Medicaid
AZAZ0155910OtherBCBS OF AZ