Healthcare Provider Details

I. General information

NPI: 1831611177
Provider Name (Legal Business Name): MICHAEL PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 CEDAR LN
TEANECK NJ
07666-1704
US

IV. Provider business mailing address

420 MOUNTAIN AVE FL 4
NEW PROVIDENCE NJ
07974-2736
US

V. Phone/Fax

Practice location:
  • Phone: 201-837-7300
  • Fax: 201-836-6426
Mailing address:
  • Phone: 908-458-8333
  • Fax: 908-530-6522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25MA11788100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: