Healthcare Provider Details

I. General information

NPI: 1477596088
Provider Name (Legal Business Name): KIE JUNG PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 10/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 WYOMING AVE
KINGSTON PA
18704
US

IV. Provider business mailing address

6 REVERE RD
MOUNTAIN TOP PA
18707
US

V. Phone/Fax

Practice location:
  • Phone: 570-552-3900
  • Fax: 570-552-3907
Mailing address:
  • Phone: 570-552-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD033477L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberMD033477L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberMD033477L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: