Provider Demographics
NPI:1063727139
Name:PARK, INDOK (DO)
Entity type:Individual
Prefix:
First Name:INDOK
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 1:2100 PFINGSTEN RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1301
Mailing Address - Country:US
Mailing Address - Phone:847-657-5840
Mailing Address - Fax:847-657-5732
Practice Address - Street 1:2100 PFINGSTEN RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026
Practice Address - Country:US
Practice Address - Phone:847-657-5840
Practice Address - Fax:847-657-5732
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036131748207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILLICENSEOther125057614
ILRES000Medicare UPIN