Provider Demographics
NPI:1497838387
Name:PARK, STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:PARK
Other - Last Name:ZWICKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6624 WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-4659
Mailing Address - Country:US
Mailing Address - Phone:314-863-3532
Mailing Address - Fax:
Practice Address - Street 1:1585 WOODLAKE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5740
Practice Address - Country:US
Practice Address - Phone:314-878-2788
Practice Address - Fax:314-878-8988
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005005835207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology