Provider Demographics
NPI:1700906815
Name:PARK, ANNE JUNE (DO)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:JUNE
Last Name:PARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JOO EUN
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:400 FRANK W BURR BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-6839
Mailing Address - Country:US
Mailing Address - Phone:201-928-2300
Mailing Address - Fax:201-692-3262
Practice Address - Street 1:400 FRANK W BURR BLVD FL 2
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-6839
Practice Address - Country:US
Practice Address - Phone:201-928-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241915207R00000X
NJ25MB08813200207RB0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02711Medicare PIN
NY00669Medicare PIN