Provider Demographics
NPI:1063073096
Name:PARK, ANGELA (DO)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 BONITA BEACH RD STE 170
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4217
Mailing Address - Country:US
Mailing Address - Phone:239-624-1050
Mailing Address - Fax:
Practice Address - Street 1:3302 BONITA BEACH RD STE 170
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4217
Practice Address - Country:US
Practice Address - Phone:239-624-1050
Practice Address - Fax:239-624-1051
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS023299207R00000X
IAR-11683207R00000X
FLOS21142207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine