Healthcare Provider Details

I. General information

NPI: 1144457623
Provider Name (Legal Business Name): JOE YOUNG PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 06/28/2023
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 TULANE AVE RM 353
NEW ORLEANS LA
70112-2865
US

IV. Provider business mailing address

1542 TULANE AVE RM 353
NEW ORLEANS LA
70112-2865
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-5230
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number274779
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: