Provider Demographics
NPI:1831366889
Name:PARK, AMY MARIE (DO)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:PARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7740 WASHINGTON VILLAGE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4056
Mailing Address - Country:US
Mailing Address - Phone:937-531-7900
Mailing Address - Fax:937-531-7901
Practice Address - Street 1:7740 WASHINGTON VILLAGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4056
Practice Address - Country:US
Practice Address - Phone:937-531-7900
Practice Address - Fax:937-531-7901
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34010269207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000731033OtherANTHEM BCBS
OH0054534Medicaid
OH0054534Medicaid
OHH028982Medicare PIN
OHH028981Medicare PIN