Provider Demographics
NPI:1467759324
Name:PARK, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
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 1:256 N SAM HOUSTON PKWY E
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-2008
Mailing Address - Country:US
Mailing Address - Phone:281-685-0458
Mailing Address - Fax:
Practice Address - Street 1:256 N SAM HOUSTON PKWY E
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-2008
Practice Address - Country:US
Practice Address - Phone:281-685-0458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-11
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8857111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor