Provider Demographics
NPI:1164964680
Name:WANTA, HEYSOOK PARK
Entity Type:Individual
Prefix:
First Name:HEYSOOK
Middle Name:PARK
Last Name:WANTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 ASHFORD AVE
Mailing Address - Street 2:
Mailing Address - City:ARDSLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10502-1602
Mailing Address - Country:US
Mailing Address - Phone:917-843-5667
Mailing Address - Fax:
Practice Address - Street 1:1315 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5304
Practice Address - Country:US
Practice Address - Phone:212-746-5077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339118207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology