Provider Demographics
NPI:1023394665
Name:PARK, JOHN MOONKEUN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MOONKEUN
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 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:515 N 162ND AVE
Practice Address - Street 2:STE. 300
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2539
Practice Address - Country:US
Practice Address - Phone:402-393-6624
Practice Address - Fax:402-393-6635
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.095909208600000X, 2086S0129X
NE265092086S0129X
IA405632086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026135100Medicaid
NE10026454700Medicaid
NE47068731713Medicaid
IA1023394665Medicaid
NE10025724800Medicaid
IA1023394665Medicaid
NE099099160Medicare PIN