Provider Demographics
NPI:1083094189
Name:PARK, YOUNG
Entity Type:Individual
Prefix:
First Name:YOUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21422 73RD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2914
Mailing Address - Country:US
Mailing Address - Phone:718-347-3500
Mailing Address - Fax:
Practice Address - Street 1:21422 73RD AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364
Practice Address - Country:US
Practice Address - Phone:718-347-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine