Provider Demographics
NPI:1407072960
Name:PARK, KEUM ZA (MD)
Entity Type:Individual
Prefix:DR
First Name:KEUM
Middle Name:ZA
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 1:55 REGENT DR
Mailing Address - Street 2:
Mailing Address - City:GILBERTS
Mailing Address - State:IL
Mailing Address - Zip Code:60136-4056
Mailing Address - Country:US
Mailing Address - Phone:847-695-6258
Mailing Address - Fax:
Practice Address - Street 1:750 S STATE ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7612
Practice Address - Country:US
Practice Address - Phone:847-742-1040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice