Provider Demographics
NPI:1114253515
Name:PARK, SUSAN JUNG
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JUNG
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:SEUNGWON
Other - Last Name:JUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2742 DOW AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7242
Mailing Address - Country:US
Mailing Address - Phone:714-665-1600
Mailing Address - Fax:
Practice Address - Street 1:11420 WARNER AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-2529
Practice Address - Country:US
Practice Address - Phone:714-549-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine