Provider Demographics
NPI:1942274535
Name:PARK, CARL H (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:H
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4060 BUTLER PIKE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1560
Mailing Address - Country:US
Mailing Address - Phone:800-331-6634
Mailing Address - Fax:267-420-1360
Practice Address - Street 1:4060 BUTLER PIKE
Practice Address - Street 2:SUITE 200
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1560
Practice Address - Country:US
Practice Address - Phone:800-331-6634
Practice Address - Fax:267-420-1360
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0006885207W00000X, 207WX0107X
NJ25MA07554800207W00000X, 207WX0107X
PAMD420861207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00020329Medicare PIN
PA069157EV6Medicare PIN
DEP00040702Medicare PIN
NJP00020344Medicare PIN
DE146852ZCWYMedicare PIN
NJ069990AHDMedicare PIN
PA001950267-0002Medicaid
DE146852ZCWYMedicare PIN
DE1942274535Medicaid
NJ069990AHDMedicare PIN
PA069157EV6Medicare PIN
NJ069990AHDMedicare PIN
DE011940A88Medicare PIN
DEP00040702Medicare PIN
PA069157FVUMedicare PIN
NJ0025585Medicaid
DE1942274535Medicaid
NJ069990C9YMedicare PIN