Healthcare Provider Details

I. General information

NPI: 1295094811
Provider Name (Legal Business Name): ROSA PARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E CHESTNUT ST UNIT 520
LOUISVILLE KY
40202-5713
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-4740
  • Fax:
Mailing address:
  • Phone: 502-588-0328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number293766
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number60025
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: