Healthcare Provider Details

I. General information

NPI: 1720219652
Provider Name (Legal Business Name): ALEXANDER JUNGHO PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MADISON ST SUITE 301
SEATTLE WA
98104-1306
US

IV. Provider business mailing address

2717 WESTERN AVE UNIT 6018
SEATTLE WA
98121-1158
US

V. Phone/Fax

Practice location:
  • Phone: 206-505-1101
  • Fax:
Mailing address:
  • Phone: 253-335-5828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberML60092948
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60309739
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: