Provider Demographics
NPI: | 1790738698 |
---|---|
Name: | PARK, SARA EQ (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | SARA |
Middle Name: | EQ |
Last Name: | PARK |
Suffix: | |
Gender: | F |
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: | PO BOX 29202 |
Mailing Address - Street 2: | COMPREHENSIVE MEDICAL & DENTAL, AZDCS, SITECODE C041-22 |
Mailing Address - City: | PHOENIX |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85038-9202 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 602-771-3638 |
Mailing Address - Fax: | 602-351-8529 |
Practice Address - Street 1: | 4000 N CENTRAL AVE |
Practice Address - Street 2: | COMPREHENSIVE MEDICAL & DENTAL, AZDCS, SITECODE C041-22 |
Practice Address - City: | PHOENIX |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85012-1959 |
Practice Address - Country: | US |
Practice Address - Phone: | 602-771-3638 |
Practice Address - Fax: | 602-351-8529 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-05-19 |
Last Update Date: | 2023-03-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | 23844 | 208000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | 339491 | Medicaid | |
AZ | 339491 | Medicaid | |
AZ | Z69710 | Medicare PIN | |
AZ | Z133791 | Medicare PIN | |
AZ | 339491 | Medicaid |