Individual
DR. GEORGE S PARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PH.D., M.P.
Contact information
Practice address
2285 BENTON RD BLDG 3, SUITE 401, BOSSIER CITY, LA 71111-7933
(318) 415-8755
(318) 746-8565
Mailing address
PO BOX 5478, BOSSIER CITY, LA 71171-5478
(318) 415-8755
(318) 746-8565
Taxonomy
Speciality
Code
Description
License number
State
103TP0016X
Prescribing (Medical) Psychologist
Primary
MP0983
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
314936
MEDICARE PTAN
LA
Enumeration date
06/08/2006
Last updated
01/11/2016
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