1760635874 NPI number — DOUGLAS S. PARK M.D. PA

Table of content: (NPI 1760635874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760635874 NPI number — DOUGLAS S. PARK M.D. PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOUGLAS S. PARK M.D. PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1760635874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
705 W. WADLEY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79705-5373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-687-4044
Provider Business Mailing Address Fax Number:
432-687-0528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 W. WADLEY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79705-5373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-687-4044
Provider Business Practice Location Address Fax Number:
432-687-0528
Provider Enumeration Date:
11/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
432-687-4044

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  F6298 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00395X . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 131459306 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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