Healthcare Provider Details

I. General information

NPI: 1538133020
Provider Name (Legal Business Name): TAE WON PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1547 S WAYNE RD
WESTLAND MI
48186
US

IV. Provider business mailing address

1547 S WAYNE RD
WESTLAND MI
48186
US

V. Phone/Fax

Practice location:
  • Phone: 734-729-3133
  • Fax: 734-729-3130
Mailing address:
  • Phone: 734-729-3133
  • Fax: 734-729-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301035528
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: