Provider Demographics
NPI:1942204680
Name:PARK, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
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 1:430 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5304
Mailing Address - Country:US
Mailing Address - Phone:269-321-6673
Mailing Address - Fax:269-324-5594
Practice Address - Street 1:430 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5304
Practice Address - Country:US
Practice Address - Phone:269-321-6673
Practice Address - Fax:269-324-5594
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063179207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4111376Medicaid
MIOM833001Medicare ID - Type Unspecified
MIG96568Medicare UPIN