Provider Demographics
NPI:1598729063
Name:PARK, RICHARD IN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:IN
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 36351
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28236-6351
Mailing Address - Country:US
Mailing Address - Phone:704-377-5772
Mailing Address - Fax:704-377-3389
Practice Address - Street 1:10502 PARK RD
Practice Address - Street 2:SUITE 150
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8479
Practice Address - Country:US
Practice Address - Phone:704-544-7500
Practice Address - Fax:704-544-5757
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97-01097207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2242617AMedicare PIN
NCG56527Medicare UPIN