Provider Demographics
NPI:1467431965
Name:PARK, SUSAN AHN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:AHN
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 1:155 E 76TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-2810
Mailing Address - Country:US
Mailing Address - Phone:646-801-7837
Mailing Address - Fax:646-351-0685
Practice Address - Street 1:155 E 76TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-2810
Practice Address - Country:US
Practice Address - Phone:646-801-7837
Practice Address - Fax:646-351-0685
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232798-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI22894Medicare UPIN
NY260AR1Medicare ID - Type Unspecified