Provider Demographics
NPI:1417064742
Name:PARK, ANTHONY J (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANTHONY
Other - Middle Name:JOON
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:8400 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:262-321-3000
Practice Address - Fax:262-321-3122
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37763207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32253600Medicaid
WI32253600Medicaid
G32129Medicare UPIN