Provider Demographics
NPI:1861497596
Name:PARK, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SEVEN WATERFRONT PLAZA
Mailing Address - Street 2:500 ALA MOANA BLVD., SUITE 300
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813
Mailing Address - Country:US
Mailing Address - Phone:808-521-1317
Mailing Address - Fax:808-533-1482
Practice Address - Street 1:30 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1600
Practice Address - Country:US
Practice Address - Phone:808-244-7627
Practice Address - Fax:808-242-6696
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD3915207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04550602Medicaid
HI0000BDJLWMedicare ID - Type Unspecified
HI04550602Medicaid