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General NPI Number Information
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NPI Number | 1376005090
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Entity Type | Individual
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Provider Name | SORA PARK MD
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Gender | Female
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Dates
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Enumeration Date | 04/02/2019
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Last Update Date | 08/23/2023
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Provider Practice Location Address
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Address Line | 519 MEMORIAL DR SE UNIT B10
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City | ATLANTA
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State | GA
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Zip | 30312-2289
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Country | US
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Telephone | 470-223-8983
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Fax |
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Provider Business Mailing Address
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Address Line | 113 S. PERRY ST. STE 206 #8276
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046
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Country | US
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Telephone | 470-223-8983
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 95846
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License Number State | GA
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