Provider Demographics
NPI:1376005090
Name:PARK, SORA (MD)
Entity Type:Individual
Prefix:
First Name:SORA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S. PERRY ST.
Mailing Address - Street 2:STE 206 #8276
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046
Mailing Address - Country:US
Mailing Address - Phone:470-223-8983
Mailing Address - Fax:
Practice Address - Street 1:519 MEMORIAL DR SE UNIT B10
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-2289
Practice Address - Country:US
Practice Address - Phone:470-223-8983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA958462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry