Provider Demographics
NPI:1396836847
Name:PARK, KWANG SE (MD)
Entity Type:Individual
Prefix:DR
First Name:KWANG
Middle Name:SE
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 1:7308 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-4124
Mailing Address - Country:US
Mailing Address - Phone:904-765-2475
Mailing Address - Fax:904-764-9476
Practice Address - Street 1:7308 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-4124
Practice Address - Country:US
Practice Address - Phone:904-765-2475
Practice Address - Fax:904-764-9476
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL27618207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15384Medicare ID - Type Unspecified
FLD52552Medicare UPIN