Provider Demographics
NPI:1851314488
Name:PARK, DANIEL S (DPM)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 PARK PL
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-2033
Mailing Address - Country:US
Mailing Address - Phone:607-734-4582
Mailing Address - Fax:607-734-4596
Practice Address - Street 1:668 PARK PL
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-2033
Practice Address - Country:US
Practice Address - Phone:607-734-4582
Practice Address - Fax:607-734-4596
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005567-1213E00000X
PASC005555213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02082488Medicaid
1851314488Medicare NSC
NYU75679Medicare UPIN
NY02082488Medicaid
NYBB5559Medicare PIN