Provider Demographics
NPI:1356300487
Name:PARK, SANGTAE (MD)
Entity Type:Individual
Prefix:
First Name:SANGTAE
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9711 SKOKIE BLVD
Mailing Address - Street 2:STE H
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1384
Mailing Address - Country:US
Mailing Address - Phone:847-676-2400
Mailing Address - Fax:847-676-2485
Practice Address - Street 1:9711 SKOKIE BLVD
Practice Address - Street 2:STE H
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1384
Practice Address - Country:US
Practice Address - Phone:847-676-2400
Practice Address - Fax:847-676-2485
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXM0855208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174078901Medicaid
TX174078901Medicaid
I31202Medicare UPIN