=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649287152
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYUNG SOOK PARK M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 12/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3484 STEVENS CREEK BLVD SUITE D
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95117-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-293-3333
-----------------------------------------------------
Fax | 408-244-3361
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3484 STEVENS CREEK BLVD SUITE D
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95117-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-293-3333
-----------------------------------------------------
Fax | 408-244-3361
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | A36838
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------