Provider Demographics
NPI:1386317667
Name:PARK, SAMUEL (DPT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8405 E HAMPDEN AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-4841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7400 E HAMPDEN AVE UNIT C-3
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-4861
Practice Address - Country:US
Practice Address - Phone:303-221-1474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-31
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000200121Medicaid