Healthcare Provider Details

I. General information

NPI: 1841377702
Provider Name (Legal Business Name): BEN H PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 S LEBANON ST
LEBANON IN
46052-2792
US

IV. Provider business mailing address

1310 S LEBANON ST
LEBANON IN
46052-2792
US

V. Phone/Fax

Practice location:
  • Phone: 765-482-7005
  • Fax:
Mailing address:
  • Phone: 765-482-7005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01027843
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: