MEDICARE: DR. GEORGE S PARK PH.D., M.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TP0016X	Prescribing (Medical) Psychologist	MP0983	LA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	314936	OTHER	LA	MEDICARE PTAN

General Provider Information

NPI Number	:	1437199031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE S PARK PH.D., M.P.

Provider Business Mailing Address
First Line	:	PO BOX 5478
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71171-5478
Country	:	US
Telephone Number	:	318-415-8755
Fax Number	:	318-746-8565

Provider Business Practice Location Address
First Line	:	2285 BENTON RD BLDG 3
Second Line	:	SUITE 401
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-7933
Country	:	US
Telephone Number	:	318-415-8755
Fax Number	:	318-746-8565

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	01/11/2016

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