Healthcare Provider Details

I. General information

NPI: 1356579627
Provider Name (Legal Business Name): KEVIN U PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 HIGHWAY 54 W SUITES 102 AND 308
FAYETTEVILLE GA
30214-4548
US

IV. Provider business mailing address

900 CIRCLE 75 SEPKWY 1700
ATLANTA GA
30339-3087
US

V. Phone/Fax

Practice location:
  • Phone: 770-460-1900
  • Fax: 770-719-1214
Mailing address:
  • Phone: 770-953-6929
  • Fax: 770-953-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number74050
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number074050
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: