Provider Demographics
NPI:1235135542
Name:PARK, HOON JAE (MD)
Entity Type:Individual
Prefix:
First Name:HOON
Middle Name:JAE
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 1:1772 SOUTH RD
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-1361
Mailing Address - Country:US
Mailing Address - Phone:845-298-6060
Mailing Address - Fax:845-298-0901
Practice Address - Street 1:1772 SOUTH RD
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-1361
Practice Address - Country:US
Practice Address - Phone:845-298-6060
Practice Address - Fax:845-298-0901
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168538208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY497001OtherMVP
NY08F602OtherBC/BS
NY08F601Medicare PIN
NY497001OtherMVP