Healthcare Provider Details

I. General information

NPI: 1780700781
Provider Name (Legal Business Name): SOO-MI MI PARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 10/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 ESSEX AVENUE
HACKENSACK NJ
07601-1215
US

IV. Provider business mailing address

493 ESSEX AVENUE
HACKENSACK NJ
07601-1215
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-9244
  • Fax: 201-996-9243
Mailing address:
  • Phone: 201-996-9244
  • Fax: 201-996-9243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number237492
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number25MA08918200
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA08918200
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08918200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: