Provider Demographics
NPI:1255396719
Name:PARK, JAMES D (DOM)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:D
Last Name:PARK
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7343 WILD OLIVE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2079
Mailing Address - Country:US
Mailing Address - Phone:505-514-2900
Mailing Address - Fax:505-884-5159
Practice Address - Street 1:6501 EAGLE ROCK AVE NE
Practice Address - Street 2:SUITE A6
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2478
Practice Address - Country:US
Practice Address - Phone:505-797-5400
Practice Address - Fax:505-797-2905
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM866 RX-1171100000X
NM2074225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM 00Q502OtherBCBS PT PROVIDER NUMBER
NMNM 00RH82OtherBCBS DOM PROVIDER NUMBER
NM45139024Medicaid
NM45139024Medicaid
NMNM00116Medicare PIN