Healthcare Provider Details

I. General information

NPI: 1326208034
Provider Name (Legal Business Name): JONG HO PARK M.D., M.P.H
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 CRYSTAL GROVE DR
LAKELAND FL
33801-6875
US

IV. Provider business mailing address

9707 63RD RD APT 3L
REGO PARK NY
11374-1610
US

V. Phone/Fax

Practice location:
  • Phone: 863-688-2334
  • Fax:
Mailing address:
  • Phone: 718-278-5138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number254362
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME119926
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: