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NPI Code Detail

MEDICARE: IH KOO PARK MD

MEDICARE: IH KOO PARK MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208600000XSurgery Physician15885GA
2208600000XSurgery Physician8922TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1902806227
Entity Type Code : Individual
Provider Name (Legal Business Name) : IH KOO PARK MD
Provider Business Mailing Address
First Line : 100 GROSS CRESCENT CIR
Second Line :
City : FT OGLETHORPE
State : GA
Zip : 30742-3643
Country : US
Telephone Number : 706-861-7275
Fax Number :
Provider Business Practice Location Address
First Line : 100 GROSS CRESCENT CIR
Second Line :
City : FT OGLETHORPE
State : GA
Zip : 30742-3643
Country : US
Telephone Number : 706-861-7275
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/28/2005
Last Update Date : 09/28/2012

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