1669974150 NPI number — MARIA PARK DO

Table of content: MARIA PARK DO (NPI 1669974150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669974150 NPI number — MARIA PARK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
MARIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1669974150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
51 MDG, UNIT 2060
Provider Second Line Business Mailing Address:
OSAN AB
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96266-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51ST OSAN MDG
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-784-2552
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2018

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 0102205884 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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