Provider Demographics
NPI:1932190766
Name:PARK, ERIC J (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 791372
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1372
Mailing Address - Country:US
Mailing Address - Phone:301-608-8375
Mailing Address - Fax:301-608-3979
Practice Address - Street 1:8600 OLD GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1422
Practice Address - Country:US
Practice Address - Phone:301-896-3100
Practice Address - Fax:301-581-0077
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060117207R00000X
MDD60117208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415096100Medicaid
00B836I06Medicare ID - Type Unspecified
MD415096100Medicaid
DC133868Medicare PIN