Provider Demographics
NPI:1851404362
Name:PARK, BETTY J (MD)
Entity Type:Individual
Prefix:DR
First Name:BETTY
Middle Name:J
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7777 FOREST LN
Mailing Address - Street 2:SUITE C-755
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2584
Mailing Address - Country:US
Mailing Address - Phone:972-566-2600
Mailing Address - Fax:972-566-2121
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:SUITE C-755
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2584
Practice Address - Country:US
Practice Address - Phone:972-566-2600
Practice Address - Fax:972-566-2121
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXM0213207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI45485Medicare UPIN
8F1704Medicare ID - Type Unspecified