Healthcare Provider Details

I. General information

NPI: 1750145629
Provider Name (Legal Business Name): SEUNGKYU BRIAN PARK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

IV. Provider business mailing address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-9262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: