Provider Demographics
NPI:1104935998
Name:PARK, BRIAN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-4627
Mailing Address - Country:US
Mailing Address - Phone:845-340-0244
Mailing Address - Fax:845-340-0141
Practice Address - Street 1:465 BROADWAY
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-4627
Practice Address - Country:US
Practice Address - Phone:845-340-0244
Practice Address - Fax:845-340-0141
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202639-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG89986Medicare UPIN
NY69M24Medicare PIN