Provider Demographics
NPI:1952304792
Name:PARK, THOMAS M (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
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 1:3334 CAPITAL MEDICAL BLVD
Mailing Address - Street 2:STE. 400
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-8405
Mailing Address - Country:US
Mailing Address - Phone:850-877-8174
Mailing Address - Fax:850-877-5636
Practice Address - Street 1:3334 CAPITAL MEDICAL BLVD
Practice Address - Street 2:STE. 400
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8405
Practice Address - Country:US
Practice Address - Phone:850-877-8174
Practice Address - Fax:850-877-5636
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85708207X00000X
GA056205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000962739AMedicaid
FL264968300Medicaid
GA000962739BMedicaid
FL51413YMedicare ID - Type UnspecifiedMARIANNA
GA000962739BMedicaid
GA20NCCMJMedicare ID - Type Unspecified
FL51413ZMedicare PIN