Healthcare Provider Details

I. General information

NPI: 1326703463
Provider Name (Legal Business Name): JIN HYUNG PARK AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E LEIGH ST FL 14
RICHMOND VA
23298-5004
US

IV. Provider business mailing address

724 BRISTOL VILLAGE DR APT 206
MIDLOTHIAN VA
23114-4636
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-0431
  • Fax: 804-628-0950
Mailing address:
  • Phone: 918-805-2583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number5583
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2201001854
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: