Provider Demographics
NPI:1003893165
Name:PARK, YOUNG SIN (MD)
Entity Type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:SIN
Last Name:PARK
Suffix:
Gender:M
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:PO BOX 840294
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0294
Mailing Address - Country:US
Mailing Address - Phone:888-344-1160
Mailing Address - Fax:972-331-3148
Practice Address - Street 1:812 HURON ROAD
Practice Address - Street 2:SUITE 520
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115
Practice Address - Country:US
Practice Address - Phone:216-861-5846
Practice Address - Fax:216-861-1720
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35038575174400000X
OH35.038575207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0893529Medicaid
OHF40600Medicare UPIN
OHPA0726447Medicare ID - Type Unspecified