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General NPI Number Information
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NPI Number | 1588649289
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Entity Type | Individual
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Provider Name | JONATHON LEX PARK MD
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Gender | Male
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Dates
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Enumeration Date | 12/14/2005
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Last Update Date | 10/09/2013
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Provider Practice Location Address
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Address Line | 110 10TH ST SE
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City | BANDON
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State | OR
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Zip | 97411-9157
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Country | US
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Telephone | 541-347-2313
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Fax | 541-347-2015
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Provider Business Mailing Address
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Address Line | 1900 WOODLAND DR
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City | COOS BAY
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State | OR
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Zip | 97420-0000
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Country | US
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Telephone | 541-267-5151
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Fax | 541-266-4507
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD23699
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License Number State | OR
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