Provider Demographics
NPI:1811014467
Name:PARK, BRIAN KEITH
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 WHITE POND DR
Mailing Address - Street 2:APT 421
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-1121
Mailing Address - Country:US
Mailing Address - Phone:330-414-6250
Mailing Address - Fax:
Practice Address - Street 1:477 WHITE POND DR
Practice Address - Street 2:APT 421
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-1121
Practice Address - Country:US
Practice Address - Phone:330-414-6250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2457550Medicaid