Provider Demographics
NPI:1477622991
Name:PARK, SANGKUN (MD)
Entity Type:Individual
Prefix:
First Name:SANGKUN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SONNY
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2120 EXCHANGE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3364
Mailing Address - Country:US
Mailing Address - Phone:503-325-5360
Mailing Address - Fax:503-325-9373
Practice Address - Street 1:2120 EXCHANGE ST
Practice Address - Street 2:STE 200
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3364
Practice Address - Country:US
Practice Address - Phone:503-325-5360
Practice Address - Fax:503-325-9373
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18585207R00000X
2471B0102X, 2471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2471B0102XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistBone Densitometry
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR061320Medicaid
WA1091644Medicaid
F73755Medicare UPIN
OR061320Medicaid