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:
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Other - Last Name:
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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:
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Provider Licenses
StateLicense IDTaxonomies
AZ23844208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ339491Medicaid
AZ339491Medicaid
AZZ69710Medicare PIN
AZZ133791Medicare PIN
AZ339491Medicaid