Provider Demographics
NPI:1235104506
Name:PARK, BYONG K (MD)
Entity Type:Individual
Prefix:
First Name:BYONG
Middle Name:K
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 1:612 RUTHERFORD AVE
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071-1217
Mailing Address - Country:US
Mailing Address - Phone:201-460-0063
Mailing Address - Fax:201-460-1684
Practice Address - Street 1:612 RUTHERFORD AVE
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071-1217
Practice Address - Country:US
Practice Address - Phone:201-460-0063
Practice Address - Fax:201-460-1684
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA45940207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3269701Medicaid
NJ519950Medicare ID - Type Unspecified
NJ3269701Medicaid