Basic Information
| Provider Information | |||||||||
| NPI: | 1497783971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2149 E WARNER RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852843494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806106100 | ||||||||
| FaxNumber: | 4804640189 | ||||||||
| Practice Location | |||||||||
| Address1: | 2149 E WARNER RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852843495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806106100 | ||||||||
| FaxNumber: | 4804640189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 01/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 4218 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 4218 | 01 | AZ | ARIZONA STATE LICENSE | OTHER | 2675627 | 05 | OH | MEDICAID | 000000483998 | 01 | OH | BC/BS OF OHIO | OTHER | 182405 | 05 | AZ | MEDICAID |