Provider Demographics
NPI:1316936115
Name:PARK, JOHN Y (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:Y
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:PO BOX 14369
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63178-4369
Mailing Address - Country:US
Mailing Address - Phone:314-523-5300
Mailing Address - Fax:
Practice Address - Street 1:226 S WOODS MILL RD
Practice Address - Street 2:STE 37W
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3662
Practice Address - Country:US
Practice Address - Phone:314-523-5300
Practice Address - Fax:314-434-3191
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108562207Y00000X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00186664OtherRAILROAD MEDICARE
MOP00186664OtherRAILROAD MEDICARE
H13710Medicare UPIN