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NPI Code Detail

MEDICARE: MRS. SUSIE YOUNGSIL PARK RDN

MEDICARE: MRS. SUSIE YOUNGSIL PARK RDN
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
1133V00000XRegistered Dietitian86119105CA

General Provider Information

NPI Number : 1891556445
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. SUSIE YOUNGSIL PARK RDN
Provider Business Mailing Address
First Line : 10530 GREENFORD DR
Second Line :
City : SAN DIEGO
State : CA
Zip : 92126-2846
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3724 JEFFERSON ST STE 104
Second Line :
City : AUSTIN
State : TX
Zip : 78731-6204
Country : US
Telephone Number : 254-319-3201
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/22/2024
Last Update Date : 12/08/2025

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