Provider Demographics
NPI:1861176182
Name:PARK, ANTHONY
Entity type:Individual
Prefix:
First Name:ANTHONY
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 1:315 S OSTEOPATHY AVE
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-6401
Mailing Address - Country:US
Mailing Address - Phone:660-785-1000
Mailing Address - Fax:660-785-1154
Practice Address - Street 1:315 S OSTEOPATHY AVE
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-6401
Practice Address - Country:US
Practice Address - Phone:660-785-1000
Practice Address - Fax:660-785-1154
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2024-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023022824207Q00000X
MO2024040709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine