Healthcare Provider Details

I. General information

NPI: 1063866689
Provider Name (Legal Business Name): TERRENCE PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 JUNCTION BLVD
ELMHURST NY
11373-5156
US

IV. Provider business mailing address

5910 JUNCTION BLVD
ELMHURST NY
11373-5156
US

V. Phone/Fax

Practice location:
  • Phone: 201-916-0735
  • Fax:
Mailing address:
  • Phone: 201-916-0735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberN007212-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: