MEDICARE: KNOELLE PARK D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	T2036	TX

General Provider Information

NPI Number	:	1013448026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KNOELLE PARK D.O.

Provider Business Mailing Address
First Line	:	2300 OLD SPANISH TRL APT 2052
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2142
Country	:	US
Telephone Number	:	972-821-2061
Fax Number	:

Provider Business Practice Location Address
First Line	:	2300 OLD SPANISH TRL APT 2052
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2142
Country	:	US
Telephone Number	:	972-821-2061
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2017
Last Update Date	:	01/04/2022

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