=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265533806
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK PLASTIC SURGERY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 01/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4008 CAPITAL DR
-----------------------------------------------------
City | ROCKY MOUNT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27804-3123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-937-5003
-----------------------------------------------------
Fax | 252-937-3020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 13219
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27709-3219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-937-5003
-----------------------------------------------------
Fax | 252-937-3020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FREDERICK K. PARK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 252-937-5003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 36793
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------