Provider Demographics
NPI:1841241387
Name:PARK, GERALD Y (MD)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:Y
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 DIAMOND PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-4321
Mailing Address - Country:US
Mailing Address - Phone:816-842-6717
Mailing Address - Fax:816-842-2574
Practice Address - Street 1:1950 DIAMOND PKWY STE 200
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-4321
Practice Address - Country:US
Practice Address - Phone:816-842-6717
Practice Address - Fax:816-842-2574
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0432487208800000X
MO2000158331208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
340018272OtherRAILROAD MEDICARE
27244012OtherBCBS
27244012OtherBCBS
MOJ71A523AMedicare PIN
MOH23933Medicare UPIN