Healthcare Provider Details

I. General information

NPI: 1043661770
Provider Name (Legal Business Name): ANDREW JOON PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 07/21/2022
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 S CLARKSON ST
ENGLEWOOD CO
80113-2811
US

IV. Provider business mailing address

3425 S CLARKSON ST
ENGLEWOOD CO
80113-2899
US

V. Phone/Fax

Practice location:
  • Phone: 303-789-8220
  • Fax:
Mailing address:
  • Phone: 303-789-8220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberDR.0059534
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberTL.0006653
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License NumberDR.0059534
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: