Provider Demographics
NPI:1205862075
Name:PARK, JOHN JOHGHYUN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOHGHYUN
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 1:2201 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1859
Mailing Address - Country:US
Mailing Address - Phone:516-572-6804
Mailing Address - Fax:
Practice Address - Street 1:2201 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1859
Practice Address - Country:US
Practice Address - Phone:516-572-6804
Practice Address - Fax:516-572-5019
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2023-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312393-01207L00000X
PAMD060486L207LP2900X
NJ25MA07512200208VP0014X
PAMD060489L208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1454830OtherAETNA
NJ317953OtherUS FAMILY HEALTH PLAN
NJ54-2177172OtherHORIZON BLUE CROSS BLUE SHIELD
NJ54-2177172OtherPROCURA
PA0288764000OtherKEYSTONE MEDICARE 65
NJ54-2177172OtherHORIZON CASUALITY
NJ54-2177172OtherCHN
NJP3729065OtherOXFORD
NJ54-2177172OtherPHCS (MULTIPLAN)
NJ54-2177172OtherHEALTH NET (TRICARE)
NJ7486999OtherCIGNA
NJ1996192OtherUNITED HEALTHCARE
NJ2814326000OtherKHPE, AMERIHEALTH, PERSONAL CHOICE
PA0172439106OtherAMERICHOICE
NJ54-2177172OtherFOCUS
NJ54-2177172OtherCHN
NJ54-2177172OtherPROCURA
NJ54-2177172OtherFOCUS
NJP3729065OtherOXFORD
NJ2814326000OtherKHPE, AMERIHEALTH, PERSONAL CHOICE
PA0017243910001Medicaid
NJ088061TU3Medicare PIN