Provider Demographics
NPI:1487609723
Name:PARK, PETER B (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:B
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:300 PERRINE RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-3627
Mailing Address - Country:US
Mailing Address - Phone:732-727-8346
Mailing Address - Fax:732-727-8345
Practice Address - Street 1:300 PERRINE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-3627
Practice Address - Country:US
Practice Address - Phone:732-727-8346
Practice Address - Fax:732-727-8345
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA070853002085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0001236Medicaid
NJ042471PZEMedicare PIN
NJ042471VA1Medicare PIN
H25171Medicare UPIN