Provider Demographics
NPI:1003070640
Name:PARK, SUSAN JIN-SUN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JIN-SUN
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 MILL ST # MCM14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-3900
Practice Address - Street 1:661 SIERRA ROSE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511
Practice Address - Country:US
Practice Address - Phone:775-982-8255
Practice Address - Fax:775-982-8251
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13322207QS0010X, 207Q00000X, 207QS0010X
CAA98140207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
12139950OtherCAQH
BD948WMedicare PIN