Provider Demographics
NPI:1346380581
Name:PARK, KI YOUNG (MD)
Entity Type:Individual
Prefix:MR
First Name:KI
Middle Name:YOUNG
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 1:14229 37TH AVE
Mailing Address - Street 2:BASEMENT
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4102
Mailing Address - Country:US
Mailing Address - Phone:718-463-1133
Mailing Address - Fax:718-463-6392
Practice Address - Street 1:14229 37TH AVE
Practice Address - Street 2:BASEMENT
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4102
Practice Address - Country:US
Practice Address - Phone:718-463-1133
Practice Address - Fax:718-463-6392
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200978208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
P904065OtherOXFORD
E05577Medicare UPIN
P904065OtherOXFORD