Provider Demographics
NPI:1114951522
Name:PARK, KYUNG SUN (MD)
Entity Type:Individual
Prefix:DR
First Name:KYUNG
Middle Name:SUN
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 1:100 STEVENS AVENUE
Mailing Address - Street 2:7TH FLOOR
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2026
Mailing Address - Country:US
Mailing Address - Phone:914-668-6366
Mailing Address - Fax:
Practice Address - Street 1:100 STEVENS AVE
Practice Address - Street 2:7TH FLOOR
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2600
Practice Address - Country:US
Practice Address - Phone:914-668-6366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157978207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00841103Medicaid
A61456Medicare UPIN
NY24D311Medicare ID - Type Unspecified