Healthcare Provider Details

I. General information

NPI: 1013113208
Provider Name (Legal Business Name): FREDERICK PARK M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 TALBOT RD S STE 500
RENTON WA
98055-5773
US

IV. Provider business mailing address

PO BOX 59028
RENTON WA
98058-2028
US

V. Phone/Fax

Practice location:
  • Phone: 425-251-5110
  • Fax: 425-793-7380
Mailing address:
  • Phone: 425-251-5110
  • Fax: 425-793-4707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number60653608
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA106773
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: