Healthcare Provider Details

I. General information

NPI: 1073515854
Provider Name (Legal Business Name): DONALD W PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E MISSOURI AVE
PHOENIX AZ
85014-2709
US

IV. Provider business mailing address

PO BOX 32530
PHOENIX AZ
85064-2530
US

V. Phone/Fax

Practice location:
  • Phone: 602-222-2221
  • Fax: 602-266-2044
Mailing address:
  • Phone: 602-265-2695
  • Fax: 602-265-5077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25318
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: