Provider Demographics
NPI:1124829783
Name:PARK, AGNES (MD)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:PARK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 HEATH ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-5909
Mailing Address - Country:US
Mailing Address - Phone:857-389-7124
Mailing Address - Fax:
Practice Address - Street 1:260 TREMONT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5603
Practice Address - Country:US
Practice Address - Phone:617-636-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207W00000X207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology