Provider Demographics
NPI:1881695930
Name:PARK, ROBERT CONRAD (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CONRAD
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:R. CONRAD
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 51587
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76206-1587
Mailing Address - Country:US
Mailing Address - Phone:940-390-2420
Mailing Address - Fax:
Practice Address - Street 1:2725 WIND RIVER LN
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-2999
Practice Address - Country:US
Practice Address - Phone:940-390-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4351207RI0011X, 207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E10203Medicare UPIN
TX479553YKTPMedicare PIN