Provider Demographics
NPI:1699781864
Name:PARK, STEPHEN MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MATTHEW
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 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:700 EAST WOODLAND DR
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-1620
Practice Address - Country:US
Practice Address - Phone:734-429-2302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061787208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3371174Medicaid
MI3371174Medicaid