Healthcare Provider Details

I. General information

NPI: 1659835569
Provider Name (Legal Business Name): IPARK PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 BARD AVENUE
STATEN ISLAND NY
10301
US

IV. Provider business mailing address

1042 HUGUENOT AVE
STATEN ISLAND NY
10312-4315
US

V. Phone/Fax

Practice location:
  • Phone: 718-717-8033
  • Fax: 718-720-6931
Mailing address:
  • Phone: 917-796-1693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. INNJEA PARK
Title or Position: OWNER
Credential: D.P.M.
Phone: 917-796-1693