Healthcare Provider Details

I. General information

NPI: 1427108695
Provider Name (Legal Business Name): MICHAEL HUGH PARK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 FITZSIMMONS DR
TACOMA WA
98431-1000
US

IV. Provider business mailing address

9040 REID ST
TACOMA WA
98431-1100
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1110
  • Fax:
Mailing address:
  • Phone: 253-968-0354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number468
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: