Provider Demographics
NPI:1770671281
Name:PARK, LEE CRANDALL (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:CRANDALL
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1205 YORK RD
Mailing Address - Street 2:SUITE 35
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6210
Mailing Address - Country:US
Mailing Address - Phone:410-321-1276
Mailing Address - Fax:410-433-8793
Practice Address - Street 1:1205 YORK RD
Practice Address - Street 2:SUITE 35
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6210
Practice Address - Country:US
Practice Address - Phone:410-321-1276
Practice Address - Fax:410-433-8793
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD00094462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D77800Medicare UPIN