Healthcare Provider Details

I. General information

NPI: 1356904866
Provider Name (Legal Business Name): DAVID PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 MAINE ST
QUINCY IL
62305-5875
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 217-214-0444
  • Fax:
Mailing address:
  • Phone: 217-223-8400
  • Fax: 217-277-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036.160411
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2022028001
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: