Provider Demographics
NPI:1023151685
Name:PARK, DAN D (DPM)
Entity type:Individual
Prefix:DR
First Name:DAN
Middle Name:D
Last Name:PARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:3231 S NATIONAL AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-888-6708
Practice Address - Fax:417-890-4143
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000787213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO118724OtherMO BLUE SHIELD
AR81727OtherARK BLUE SHIELD
MO309802700Medicaid
MO000021454Medicare PIN
AR81727OtherARK BLUE SHIELD