Provider Demographics
NPI:1831650043
Name:PARK, PETER K (DO)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:K
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 1:3909 9TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5134
Mailing Address - Country:US
Mailing Address - Phone:314-362-5000
Mailing Address - Fax:
Practice Address - Street 1:3909 9TH AVE SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5134
Practice Address - Country:US
Practice Address - Phone:360-570-3460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023000432208100000X
MO2020011741390200000X
390200000X
WAOP614839722081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program