Provider Demographics
NPI:1497783971
Name:PARK, EDWARD Y (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:Y
Last Name:PARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 E WARNER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3494
Mailing Address - Country:US
Mailing Address - Phone:480-610-6100
Mailing Address - Fax:480-464-0189
Practice Address - Street 1:2149 E WARNER RD STE 102
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-3495
Practice Address - Country:US
Practice Address - Phone:480-610-6100
Practice Address - Fax:480-464-0189
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4218207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4218OtherARIZONA STATE LICENSE
OH2675627Medicaid
OH000000483998OtherBC/BS OF OHIO
AZ182405Medicaid
AZ182405Medicaid
OH2675627Medicaid
AZZ130069Medicare PIN