Provider Demographics
NPI:1891848412
Name:PARK, JOSEPH (DO)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
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 1:3805 MAIN ST STE 112
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-2853
Mailing Address - Country:US
Mailing Address - Phone:972-370-0004
Mailing Address - Fax:972-370-0088
Practice Address - Street 1:3805 MAIN ST STE 112
Practice Address - Street 2:
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-2853
Practice Address - Country:US
Practice Address - Phone:972-370-0004
Practice Address - Fax:972-370-0088
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167574603Medicaid
TX167574602Medicaid
TX167574603Medicaid
TX611803Medicare ID - Type Unspecified