Provider Demographics
NPI:1235107905
Name:PARK, YOUNG WON (MD)
Entity Type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:WON
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 1:220 CLIFFSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 EAST WATER STREET
Practice Address - Street 2:
Practice Address - City:MUNCY
Practice Address - State:PA
Practice Address - Zip Code:17756-1966
Practice Address - Country:US
Practice Address - Phone:570-546-4192
Practice Address - Fax:570-546-4138
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK000555L171100000X
PAMD027494E208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008729990003Medicaid
PA1554158OtherUNITEDHEALTHCARE
PA072549OtherFIRST PRIORITY HEALTH
PAC33002OtherHEALTHAMERICA
PA183700OtherHIGHMARK BLUE SHIELD
PA50054361OtherCAPITAL BLUE CROSS
PA547104OtherAETNA
PA183700OtherHIGHMARK BLUE SHIELD
PA250010790Medicare PIN
PAC33002OtherHEALTHAMERICA