Provider Demographics
NPI:1316980295
Name:PARK, KEN (MD)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
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 1:8994 TOUR DR STE 210
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-2036
Mailing Address - Country:US
Mailing Address - Phone:972-449-5900
Mailing Address - Fax:972-449-7100
Practice Address - Street 1:8994 TOUR DR STE 210
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-2036
Practice Address - Country:US
Practice Address - Phone:972-449-5900
Practice Address - Fax:972-449-7100
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8962207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX352501ZG28Medicare PIN
TX352501ZG29Medicare PIN
TXH05472Medicare UPIN
TX144818501Medicaid
TX8A4737Medicare PIN