Provider Demographics
NPI:1497744502
Name:PARK, RAYMOND DH (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:DH
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:PO BOX 69737
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98168-8737
Mailing Address - Country:US
Mailing Address - Phone:206-431-0138
Mailing Address - Fax:206-246-5819
Practice Address - Street 1:12303 NE 130TH LN
Practice Address - Street 2:SUITE 325
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3099
Practice Address - Country:US
Practice Address - Phone:425-899-3135
Practice Address - Fax:425-899-3143
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000356852084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8241622Medicaid
WA137538OtherWA STATE L&I
WAG8869762Medicare PIN
WA8241622Medicaid
WAG94854Medicare UPIN
WAAB14935Medicare PIN
WAG8868468Medicare PIN