Healthcare Provider Details

I. General information

NPI: 1497838387
Provider Name (Legal Business Name): STEPHANIE PARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE PARK ZWICKER

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 WOODLAKE DR SUITE 201
CHESTERFIELD MO
63017-5740
US

IV. Provider business mailing address

6624 WATERMAN AVE
SAINT LOUIS MO
63130-4659
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-2788
  • Fax: 314-878-8988
Mailing address:
  • Phone: 314-863-3532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number2005005835
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: