Healthcare Provider Details

I. General information

NPI: 1568916625
Provider Name (Legal Business Name): JULIE PARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2016
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 N KEENE ST WOMEN'S AND CHILDREN'S HOSPITAL
COLUMBIA MO
65201-6626
US

IV. Provider business mailing address

400 N KEENE ST SOUTH PAVILION
COLUMBIA MO
65201-6626
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-4438
  • Fax: 573-884-9992
Mailing address:
  • Phone: 573-882-4438
  • Fax: 573-884-9992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2016022755
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberMD197784
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: