Provider Demographics
NPI:1225224652
Name:PARK, MIKYUNG (LIC AC)
Entity Type:Individual
Prefix:
First Name:MIKYUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 HILL RD APT 210
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-4319
Mailing Address - Country:US
Mailing Address - Phone:617-665-1400
Mailing Address - Fax:
Practice Address - Street 1:1493 CAMBRIDGE HOSPITAL
Practice Address - Street 2:4 WEST
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139
Practice Address - Country:US
Practice Address - Phone:617-665-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA233820171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist