Provider Demographics
NPI:1295713444
Name:PARK, ROGER TIMOTHY (DO)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:TIMOTHY
Last Name:PARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4088 US-91
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84318
Mailing Address - Country:US
Mailing Address - Phone:435-563-4900
Mailing Address - Fax:
Practice Address - Street 1:4088 US-91
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:UT
Practice Address - Zip Code:84318
Practice Address - Country:US
Practice Address - Phone:435-563-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8647453-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine