Basic Information
| Provider Information | |||||||||
| NPI: | 1669761748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | OLIVIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | W180N8085 TOWN HALL RD | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530513518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622573550 | ||||||||
| FaxNumber: | 2625185052 | ||||||||
| Practice Location | |||||||||
| Address1: | W180N8085 TOWN HALL RD | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530513518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622573550 | ||||||||
| FaxNumber: | 2625185052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2011 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 01076676A | IN | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 72450 | WI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.