Healthcare Provider Details

I. General information

NPI: 1285997700
Provider Name (Legal Business Name): MICHAEL PARK D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 COLLIER RD NW SUITE 775
ATLANTA GA
30309-1613
US

IV. Provider business mailing address

35 COLLIER RD NW SUITE 775
ATLANTA GA
30309-1613
US

V. Phone/Fax

Practice location:
  • Phone: 404-350-1122
  • Fax: 404-609-7608
Mailing address:
  • Phone: 404-350-1122
  • Fax: 404-609-7608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number074051
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: