Provider Demographics
NPI:1316396906
Name:PARK, JOANN (MD)
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 WISHARD BLVD STE 4110
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-4164
Mailing Address - Country:US
Mailing Address - Phone:317-944-8162
Mailing Address - Fax:
Practice Address - Street 1:1002 WISHARD BLVD STE 4110
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4164
Practice Address - Country:US
Practice Address - Phone:317-944-8162
Practice Address - Fax:317-944-8163
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1510632084P0804X
IN01092460A2084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry