Provider Demographics
NPI:1477596088
Name:PARK, KIE JUNG (MD)
Entity Type:Individual
Prefix:
First Name:KIE
Middle Name:JUNG
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 1:6 REVERE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707
Mailing Address - Country:US
Mailing Address - Phone:570-552-3900
Mailing Address - Fax:
Practice Address - Street 1:562 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704
Practice Address - Country:US
Practice Address - Phone:570-552-3900
Practice Address - Fax:570-552-3907
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033477L2084P0802X, 2084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA007338991Medicaid
PA162163Medicare PIN
PA007338991Medicaid