Provider Demographics
NPI:1255372827
Name:PARK, JOHN C (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
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 1:2177 OAK TREE RD
Mailing Address - Street 2:#203
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1082
Mailing Address - Country:US
Mailing Address - Phone:908-822-0070
Mailing Address - Fax:
Practice Address - Street 1:2177 OAK TREE RD
Practice Address - Street 2:#203
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1082
Practice Address - Country:US
Practice Address - Phone:908-822-0070
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07540000207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
077227Medicare ID - Type Unspecified
I03361Medicare UPIN