Provider Demographics
NPI:1902882244
Name:PARK, JAMES VANCE (MD)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:VANCE
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-0021
Mailing Address - Country:US
Mailing Address - Phone:563-324-8160
Mailing Address - Fax:563-324-8486
Practice Address - Street 1:1227 E RUSHOLME ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2498
Practice Address - Country:US
Practice Address - Phone:563-421-1000
Practice Address - Fax:563-421-7889
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28906207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1091116Medicaid
IA1091116Medicaid
15205Medicare ID - Type Unspecified