MEDICARE: ANDREW JOHN PARK M.D.

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	208800000X	Urology Physician	35.145109	OH

General Provider Information

NPI Number	:	1730610718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW JOHN PARK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 7527
Second Line	:
City	:	DUBLIN
State	:	OH
Zip	:	43017-0727
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 CRICKET LN
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-4104
Country	:	US
Telephone Number	:	567-309-2040
Fax Number	:	567-309-2045

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

Provider Enumeration Date	:	03/22/2017
Last Update Date	:	07/25/2022

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