=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194023135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE FAMILY MEDICAL PRACTICE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2011
-----------------------------------------------------
Last Update Date | 03/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21008 35TH AVE
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-1431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-229-4090
-----------------------------------------------------
Fax | 866-457-6793
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21008 35TH AVE
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-1431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-229-4090
-----------------------------------------------------
Fax | 866-457-6793
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JIA PARK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-229-4090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------