Provider Demographics
NPI:1609062488
Name:PARK, KYLE K (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:K
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 1:107 HOUPT DRIVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-9201
Mailing Address - Country:US
Mailing Address - Phone:419-294-5757
Mailing Address - Fax:419-209-0623
Practice Address - Street 1:107 HOUPT DRIVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-9201
Practice Address - Country:US
Practice Address - Phone:419-294-5757
Practice Address - Fax:419-209-0623
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35037628207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0408811Medicaid
OH0453563Medicare PIN
OH0408811Medicaid