Provider Demographics
NPI:1699849034
Name:GREGORY PARK MD INC
Entity Type:Organization
Organization Name:GREGORY PARK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-244-7627
Mailing Address - Street 1:SEVEN WATERFRONT PLAZA
Mailing Address - Street 2:500 ALA MOANA BLVD., SUITE 300
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813
Mailing Address - Country:US
Mailing Address - Phone:808-521-1317
Mailing Address - Fax:808-533-1482
Practice Address - Street 1:30 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1600
Practice Address - Country:US
Practice Address - Phone:808-244-7627
Practice Address - Fax:808-243-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-18
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD3915207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HID36405Medicare UPIN