Provider Demographics
NPI:1780642710
Name:PARK, WILLIAM ISAIAH IV (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ISAIAH
Last Name:PARK
Suffix:IV
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 1:1505 DAPHNE AVE
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-4298
Mailing Address - Country:US
Mailing Address - Phone:251-625-2663
Mailing Address - Fax:251-625-3198
Practice Address - Street 1:1505 DAPHNE AVE
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4298
Practice Address - Country:US
Practice Address - Phone:251-625-2663
Practice Address - Fax:251-625-3198
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00024958207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0126962Medicaid
631187140OtherTAX ID
AL051552744Medicaid
AL051512928OtherBCBS
200045417OtherRAILROAD MEDICARE
631187140OtherTAX ID
AL051552744Medicare ID - Type Unspecified
MS0126962Medicaid