Provider Demographics
NPI:1194739375
Name:PARK, JOHN STANITSKI (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STANITSKI
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 1:2002 MEDICAL PKWY
Mailing Address - Street 2:SUITE 235
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3046
Mailing Address - Country:US
Mailing Address - Phone:410-266-2770
Mailing Address - Fax:410-841-6251
Practice Address - Street 1:2002 MEDICAL PKWY
Practice Address - Street 2:SUITE 235
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3046
Practice Address - Country:US
Practice Address - Phone:410-266-2770
Practice Address - Fax:410-841-6251
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA954022085R0202X
MDD00581932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00471895OtherPTAN
MDQ932OtherAAD AA COUNTY
MDCN6292OtherRR MEDICARE SHIPLEYS
MDS629Q703OtherMEDICARE ARA PTAN
MD10690030OtherBCBS
MD021965A80OtherAAD PG COUNTY
MD412620300Medicaid
MD545LQ923OtherSHIPLEYS MEDICARE
MDI66836Medicare UPIN
MDS629Q703Medicare PIN