Provider Demographics
NPI:1518006725
Name:PARK, JOHN I (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:I
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 1:109 CROSSROADS ROAD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SCOTTDALE
Mailing Address - State:PA
Mailing Address - Zip Code:15683
Mailing Address - Country:US
Mailing Address - Phone:724-887-7421
Mailing Address - Fax:724-887-4145
Practice Address - Street 1:109 CROSSROADS RD
Practice Address - Street 2:SUITE 6
Practice Address - City:SCOTTDALE
Practice Address - State:PA
Practice Address - Zip Code:15683-2458
Practice Address - Country:US
Practice Address - Phone:724-887-7421
Practice Address - Fax:724-887-4145
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034829E2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
197526OtherHIGHMARK
PA0011173760007Medicaid
C33311Medicare UPIN
PA0011173760007Medicaid