Provider Demographics
NPI:1043359037
Name:PARK, KYE SOO (MD)
Entity Type:Individual
Prefix:DR
First Name:KYE
Middle Name:SOO
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 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-397-3370
Mailing Address - Fax:360-604-1749
Practice Address - Street 1:700 NE 87TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1913
Practice Address - Country:US
Practice Address - Phone:360-397-3370
Practice Address - Fax:360-604-1749
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2004-0437207R00000X
WAMD60145123207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0262973OtherL & I
WA1043359037Medicaid