Healthcare Provider Details

I. General information

NPI: 1427256635
Provider Name (Legal Business Name): KYONG PARK M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 10/25/2020
Certification Date: 10/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 BINNEY ST
CAMBRIDGE MA
02142-1011
US

IV. Provider business mailing address

PO BOX 514
GREAT FALLS VA
22066-0514
US

V. Phone/Fax

Practice location:
  • Phone: 571-353-0256
  • Fax:
Mailing address:
  • Phone: 518-285-0864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR-8207
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number0101244536
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number253655
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: