Provider Demographics
NPI:1861573024
Name:PARK, ROBERT I (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:I
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1701 OLD VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28791-3772
Mailing Address - Country:US
Mailing Address - Phone:828-693-1773
Mailing Address - Fax:828-692-3297
Practice Address - Street 1:1701 OLD VILLAGE RD
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28791-3772
Practice Address - Country:US
Practice Address - Phone:828-693-1773
Practice Address - Fax:828-692-3297
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00304207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906514Medicaid
2064590OtherMEDICARE
NC5906514Medicaid