Healthcare Provider Details

I. General information

NPI: 1245337153
Provider Name (Legal Business Name): JERRY W. PARK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9222 N NEWPORT HWY STE 1
SPOKANE WA
99218-1235
US

IV. Provider business mailing address

7511 N PANORAMA DR
SPOKANE WA
99208-8431
US

V. Phone/Fax

Practice location:
  • Phone: 509-467-4545
  • Fax: 509-467-2304
Mailing address:
  • Phone: 509-466-3089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00001729
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: