Provider Demographics
NPI:1144576331
Name:PARK, YONGTACK
Entity Type:Individual
Prefix:
First Name:YONGTACK
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 1:800 PALISADE AVENUE
Mailing Address - Street 2:#308
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024
Mailing Address - Country:US
Mailing Address - Phone:347-334-6860
Mailing Address - Fax:347-602-8662
Practice Address - Street 1:800 PALISADE AVENUE
Practice Address - Street 2:#308
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024
Practice Address - Country:US
Practice Address - Phone:347-334-6860
Practice Address - Fax:347-602-8662
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2022-11-08
Deactivation Date:2013-02-19
Deactivation Code:
Reactivation Date:2022-11-08
Provider Licenses
StateLicense IDTaxonomies
NY017697225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist