Healthcare Provider Details

I. General information

NPI: 1053328625
Provider Name (Legal Business Name): AMY PARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE # DESKA81
CLEVELAND OH
44195-2927
US

IV. Provider business mailing address

106 IRVING ST NW SUITE 405 SOUTH
WASHINGTON DC
20010-2927
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-6277
  • Fax:
Mailing address:
  • Phone: 202-877-6526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number35.088057
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: