Provider Demographics
NPI:1265625941
Name:PARK, JUSTIN (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
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 1:1600 CRAIN HWY S
Mailing Address - Street 2:SUITE 401
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5577
Mailing Address - Country:US
Mailing Address - Phone:410-768-5050
Mailing Address - Fax:410-768-7830
Practice Address - Street 1:1600 CRAIN HWY S
Practice Address - Street 2:SUITE 401
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5577
Practice Address - Country:US
Practice Address - Phone:410-768-5050
Practice Address - Fax:410-768-7830
Is Sole Proprietor?:No
Enumeration Date:2007-08-25
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43955207XS0117X
MDD0073546207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD253616OtherJHHC
MD6831-0019OtherCAREFIRST
KYK007170OtherMEDICARE PTAN-- NORTON LEATHERMAN SPINE
MD231508400Medicaid
MD6029607OtherCIGNA
MD9804676OtherAETNA PPO
MD8543972OtherAETNA HMO
MD8543972OtherAETNA HMO