=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659835569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IPARK PODIATRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2019
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 970 BARD AVENUE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-717-8033
-----------------------------------------------------
Fax | 718-720-6931
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1042 HUGUENOT AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312-4315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-796-1693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. INNJEA PARK
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 917-796-1693
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------