Healthcare Provider Details

I. General information

NPI: 1225587793
Provider Name (Legal Business Name): SAMUEL PARK MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 1ST ST UNIT 551
MINEOLA NY
11501-5025
US

IV. Provider business mailing address

160 1ST ST UNIT 551
MINEOLA NY
11501-5025
US

V. Phone/Fax

Practice location:
  • Phone: 516-619-8098
  • Fax:
Mailing address:
  • Phone: 516-619-8098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL J PARK
Title or Position: PRESIDENT
Credential: MD
Phone: 516-619-8098