Provider Demographics
NPI:1700313053
Name:PARK, HIROMICHI S (DO)
Entity Type:Individual
Prefix:
First Name:HIROMICHI
Middle Name:S
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 1:3483 S EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-3314
Mailing Address - Country:US
Mailing Address - Phone:702-309-2311
Mailing Address - Fax:
Practice Address - Street 1:3483 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-3314
Practice Address - Country:US
Practice Address - Phone:702-309-2311
Practice Address - Fax:702-309-2177
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPG182644390200000X
NVDO3259207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program