Provider Demographics
NPI:1407964547
Name:PARK, FREDERICK KIM (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:KIM
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 1:4008 CAPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804
Mailing Address - Country:US
Mailing Address - Phone:252-937-5003
Mailing Address - Fax:252-937-3020
Practice Address - Street 1:4008 CAPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804
Practice Address - Country:US
Practice Address - Phone:252-937-5003
Practice Address - Fax:252-937-3020
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36793208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC65228OtherBCBS
NC7965228Medicaid
NCP00159404OtherRAILROAD MEDICARE
NCDC2876OtherMEDICARE RAILROAD
NC7965228Medicaid
NC65228OtherBCBS