Provider Demographics
NPI:1992707137
Name:PARK, EUGENE L (MD)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:L
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 1:8580 MAGELLAN PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1149
Mailing Address - Country:US
Mailing Address - Phone:804-765-6100
Mailing Address - Fax:804-765-6101
Practice Address - Street 1:40 MEDICAL PARK BLVD STE D
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805
Practice Address - Country:US
Practice Address - Phone:804-765-6100
Practice Address - Fax:804-765-6101
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101247088208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1992707137Medicaid
AZ860777Medicaid
0288760001Medicare NSC
AZ860777Medicaid