Individual
DR. JONATHON LEX PARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
110 10TH ST SE, BANDON, OR 97411-9157
(541) 347-2313
(541) 347-2015
Mailing address
1900 WOODLAND DR, COOS BAY, OR 97420-0000
(541) 267-5151
(541) 266-4507
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD23699
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
080182358
RR MEDICARE PTAN NUMBER
OR
01
—
1407812365
NBMC GROUP NPI NUMBER
OR
05
—
286887
—
OR
01
—
93063551
GROUP TAX ID NUMBER
OR
01
—
CD8723
RR MEDICARE GROUP NUMBER
OR
01
—
R0000WFBTV
MEDICARE GROUP PIN NUMBER
OR
Enumeration date
12/14/2005
Last updated
10/09/2013
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