Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207XS0117X | Orthopaedic Spine Surgeon | 43955 | KY |
Y | 207XS0117X | Orthopaedic Spine Surgeon | D0073546 | MD |
NPI | 1265625941 |
---|---|
Provider Name | Justin Park |
First Address | Glen Burnie, MD 21061-5577 |
Second Address | Glen Burnie, MD 21061-5577 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2007 |
Last Update Date | 15/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
231508400 | (05) | MD |
253616 | JHHC (01) | MD |
6029607 | CIGNA (01) | MD |
6831-0019 | CAREFIRST (01) | MD |
8543972 | AETNA HMO (01) | MD |
9804676 | AETNA PPO (01) | MD |
K007170 | MEDICARE PTAN-- NORTON LEATHERMAN SPINE (01) | KY |