MEDICARE: DR. SONNY YONG PARK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MD22311	ME
2	207P00000X	Emergency Medicine Physician	25559	SC
3	207Q00000X	Family Medicine Physician	25MA10015400	NJ
4	207P00000X	Emergency Medicine Physician	01078315A	IN
5	207P00000X	Emergency Medicine Physician	1987320	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	33329	OTHER	AZ	STATE MEDICAL LICENSE

General Provider Information

NPI Number	:	1720071277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SONNY YONG PARK MD

Provider Business Mailing Address
First Line	:	1988 KINGS GATE LN
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-8191
Country	:	US
Telephone Number	:	864-640-0395
Fax Number	:

Provider Business Practice Location Address
First Line	:	1988 KINGS GATE LN
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-8191
Country	:	US
Telephone Number	:	864-640-0395
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	09/15/2025

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