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General NPI Number Information
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NPI Number | 1144337460
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Entity Type | Individual
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Provider Name | JOHN R PARK MD
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Gender | Male
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Dates
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Enumeration Date | 08/23/2006
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Last Update Date | 08/26/2015
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Provider Practice Location Address
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Address Line | 248 MCHENRY ST
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City | BURLINGTON
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State | WI
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Zip | 53105
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Country | US
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Telephone | 262-767-8260
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Fax | 262-767-8212
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Provider Business Mailing Address
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Address Line | 30805 CEDAR DR
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City | BURLINGTON
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State | WI
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Zip | 53105-9479
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Country | US
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Telephone | 262-767-0706
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Fax | 262-767-0706
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 23675
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License Number State | WI
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