1255396719 NPI number — DR. JAMES D PARK DOM

Table of content: DR. JAMES D PARK DOM (NPI 1255396719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255396719 NPI number — DR. JAMES D PARK DOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
JAMES
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DOM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255396719
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7343 WILD OLIVE AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87113-2079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-514-2900
Provider Business Mailing Address Fax Number:
505-884-5159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6501 EAGLE ROCK AVE NE
Provider Second Line Business Practice Location Address:
SUITE A6
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87113-2478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-797-5400
Provider Business Practice Location Address Fax Number:
505-797-2905
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  866 RX-1 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 2074 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NM 00Q502 . This is a "BCBS PT PROVIDER NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM 00RH82 . This is a "BCBS DOM PROVIDER NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 45139024 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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