Provider Demographics
NPI:1386028561
Name:PARK, JEONGSOO
Entity Type:Individual
Prefix:
First Name:JEONGSOO
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 213TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2854
Mailing Address - Country:US
Mailing Address - Phone:929-264-1293
Mailing Address - Fax:
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:929-264-1293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program