Provider Demographics
NPI:1093363574
Name:PARK, DAVID MANSUG (OMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MANSUG
Last Name:PARK
Suffix:
Gender:M
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-4857
Mailing Address - Country:US
Mailing Address - Phone:352-759-8275
Mailing Address - Fax:352-234-3625
Practice Address - Street 1:1514 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-4857
Practice Address - Country:US
Practice Address - Phone:352-759-8275
Practice Address - Fax:352-234-3625
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4075171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1093363574OtherACUPUNCTURE PHYSICIAN
FL1093363574OtherPAIN CONTROL BY ACUPUNCTURE, METABOLIC MATTER CARE BY ENZYMES