Healthcare Provider Details

I. General information

NPI: 1497783971
Provider Name (Legal Business Name): EDWARD Y PARK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2149 E WARNER RD STE 102
TEMPE AZ
85284-3495
US

IV. Provider business mailing address

2149 E WARNER RD SUITE 101
TEMPE AZ
85284-3494
US

V. Phone/Fax

Practice location:
  • Phone: 480-610-6100
  • Fax: 480-464-0189
Mailing address:
  • Phone: 480-610-6100
  • Fax: 480-464-0189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4218
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: