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General NPI Number Information
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NPI Number | 1477596088
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Entity Type | Individual
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Provider Name | KIE JUNG PARK MD
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Gender | Male
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Dates
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Enumeration Date | 06/13/2006
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Last Update Date | 10/02/2009
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Provider Practice Location Address
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Address Line | 562 WYOMING AVE
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City | KINGSTON
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State | PA
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Zip | 18704
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Country | US
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Telephone | 570-552-3900
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Fax | 570-552-3907
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Provider Business Mailing Address
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Address Line | 6 REVERE RD
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City | MOUNTAIN TOP
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State | PA
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Zip | 18707
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Country | US
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Telephone | 570-552-3900
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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 | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number | MD033477L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 2084P0805X
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Taxonomy Name | Geriatric Psychiatry Physician
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License Number | MD033477L
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MD033477L
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License Number State | PA
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