Healthcare Provider Details

I. General information

NPI: 1730170770
Provider Name (Legal Business Name): HYO KWON PARK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13855 COURTHOUSE RD
DINWIDDIE VA
23841-2254
US

IV. Provider business mailing address

P.O. BOX 70 1508 K-V ROAD
VICTORIA VA
23974
US

V. Phone/Fax

Practice location:
  • Phone: 804-469-3731
  • Fax: 804-469-5307
Mailing address:
  • Phone: 434-696-2165
  • Fax: 434-696-1557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102202692
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: