Healthcare Provider Details

I. General information

NPI: 1972130938
Provider Name (Legal Business Name): LISA KYOUN PARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COMMUNITY DR
MANHASSET NY
11030-3816
US

IV. Provider business mailing address

300 COMMUNITY DR
MANHASSET NY
11030-3816
US

V. Phone/Fax

Practice location:
  • Phone: 516-562-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number3975508
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: