Healthcare Provider Details

I. General information

NPI: 1063578961
Provider Name (Legal Business Name): JOHN KYUN PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 LAKE DR SUITE 301
RALEIGH NC
27607-6688
US

IV. Provider business mailing address

2601 LAKE DR SUITE 301
RALEIGH NC
27607-6688
US

V. Phone/Fax

Practice location:
  • Phone: 919-782-5911
  • Fax:
Mailing address:
  • Phone: 919-782-5911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number2008-00439
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: