Provider Demographics
NPI:1790780211
Name:PARK, DAVID J (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:331 OLCOTT DR
Mailing Address - Street 2:STE U3
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-9601
Mailing Address - Country:US
Mailing Address - Phone:802-295-6132
Mailing Address - Fax:802-295-1358
Practice Address - Street 1:331 OLCOTT DR
Practice Address - Street 2:STE U3
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-9601
Practice Address - Country:US
Practice Address - Phone:802-295-6132
Practice Address - Fax:802-295-1358
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT042-0010755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010649Medicaid
VT8000079Medicaid
VT8000079Medicaid
VTVN3430Medicare ID - Type Unspecified