Provider Demographics
NPI:1548983570
Name:PARK, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 FAIRMOUNT AVE UNIT 1236
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-2487
Mailing Address - Country:US
Mailing Address - Phone:714-742-4999
Mailing Address - Fax:
Practice Address - Street 1:100 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-6132
Practice Address - Country:US
Practice Address - Phone:714-742-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program