Provider Demographics
NPI:1386195980
Name:PARK, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6954 VAUGHN RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-1368
Mailing Address - Country:US
Mailing Address - Phone:334-301-8860
Mailing Address - Fax:334-512-9979
Practice Address - Street 1:6954 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-1368
Practice Address - Country:US
Practice Address - Phone:334-301-8860
Practice Address - Fax:334-512-9979
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0000665171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist