Provider Demographics
NPI:1225587793
Name:SAMUEL PARK MD, PLLC
Entity type:Organization
Organization Name:SAMUEL PARK MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-619-8098
Mailing Address - Street 1:160 1ST ST UNIT 551
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-5025
Mailing Address - Country:US
Mailing Address - Phone:516-619-8098
Mailing Address - Fax:
Practice Address - Street 1:160 1ST ST UNIT 551
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-5025
Practice Address - Country:US
Practice Address - Phone:516-619-8098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-26
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 208000000X
NY285562208000000X
CODR.0057133207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty