Provider Demographics
NPI:1245347392
Name:PARK, YOUNG R (MD)
Entity type:Individual
Prefix:
First Name:YOUNG
Middle Name:R
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:PO BOX 632621
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2621
Mailing Address - Country:US
Mailing Address - Phone:908-653-9399
Mailing Address - Fax:908-653-9305
Practice Address - Street 1:1343 N FOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45501
Practice Address - Country:US
Practice Address - Phone:937-390-5029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041645P207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0397682Medicaid
OH0397682Medicaid
0419082Medicare ID - Type Unspecified