Healthcare Provider Details

I. General information

NPI: 1801919980
Provider Name (Legal Business Name): SONNY PARK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 EXCHANGE ST STE 200
ASTORIA OR
97103-3365
US

IV. Provider business mailing address

2120 EXCHANGE ST STE 200
ASTORIA OR
97103-3365
US

V. Phone/Fax

Practice location:
  • Phone: 503-325-5360
  • Fax: 503-325-9373
Mailing address:
  • Phone: 503-325-5360
  • Fax: 503-325-9373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD18585
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SANGKUN (SONNY) PARK
Title or Position: OWNER
Credential: MD
Phone: 503-325-5360