=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205563319
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NY FAMILY MEDICINE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2022
-----------------------------------------------------
Last Update Date | 08/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14809 NORTHERN BLVD STE 1K
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-4308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-506-0325
-----------------------------------------------------
Fax | 347-506-0314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14809 NORTHERN BLVD STE 1K
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-4308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-506-0325
-----------------------------------------------------
Fax | 347-506-0314
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL DOYOUNG PARK
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 347-506-0325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------