Provider Demographics
NPI:1629450804
Name:PARK, DAL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DALNAM
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2000 W BETHANY HOME RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2443
Practice Address - Country:US
Practice Address - Phone:602-246-5658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR75295390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program