Provider Demographics
NPI:1851769707
Name:PARK, JOEL A
Entity Type:Individual
Prefix:MR
First Name:JOEL
Middle Name:A
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 1:1821 DORA AVE
Mailing Address - Street 2:APARTMENT 244
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5765
Mailing Address - Country:US
Mailing Address - Phone:352-508-5089
Mailing Address - Fax:352-435-4605
Practice Address - Street 1:1821 DORA AVE
Practice Address - Street 2:APARTMENT 244
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5765
Practice Address - Country:US
Practice Address - Phone:352-508-5089
Practice Address - Fax:352-435-4605
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide