Healthcare Provider Details

I. General information

NPI: 1588114060
Provider Name (Legal Business Name): PRIME DIAGNOSTICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 BROAD AVE N9
PALISADES PARK NJ
07650-2717
US

IV. Provider business mailing address

118 BROAD AVE N9
PALISADES PARK NJ
07650-2717
US

V. Phone/Fax

Practice location:
  • Phone: 201-482-0439
  • Fax:
Mailing address:
  • Phone: 201-482-0439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA07699600
License Number StateNJ

VIII. Authorized Official

Name: DR. CHANG S PARK
Title or Position: OWNER
Credential: M.D.
Phone: 20148200439