Healthcare Provider Details

I. General information

NPI: 1649287152
Provider Name (Legal Business Name): KYUNG SOOK PARK M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 12/18/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3484 STEVENS CREEK BLVD SUITE D
SAN JOSE CA
95117-1000
US

IV. Provider business mailing address

3484 STEVENS CREEK BLVD SUITE D
SAN JOSE CA
95117-1000
US

V. Phone/Fax

Practice location:
  • Phone: 408-293-3333
  • Fax: 408-244-3361
Mailing address:
  • Phone: 408-293-3333
  • Fax: 408-244-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA36838
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: