Healthcare Provider Details

I. General information

NPI: 1730220666
Provider Name (Legal Business Name): YOHAN PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 01/28/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4223 212TH ST UNIT 1A
BAYSIDE NY
11361-2979
US

IV. Provider business mailing address

4223 212TH ST UNIT 1B
BAYSIDE NY
11361-2979
US

V. Phone/Fax

Practice location:
  • Phone: 718-229-7337
  • Fax: 718-229-7333
Mailing address:
  • Phone: 718-229-7337
  • Fax: 718-229-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number236369
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: