Provider Demographics
NPI:1063774693
Name:PARK, ANDREW J (DC, MS, MS LAC)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:DC, MS, MS LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 7TH AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-5230
Mailing Address - Country:US
Mailing Address - Phone:516-813-7099
Mailing Address - Fax:646-688-4765
Practice Address - Street 1:850 7TH AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-5230
Practice Address - Country:US
Practice Address - Phone:516-813-7099
Practice Address - Fax:646-688-4765
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012187-1111N00000X, 111NN1001X
NYX012187111NS0005X
NY004991171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No171100000XOther Service ProvidersAcupuncturist