Provider Demographics
NPI:1497161293
Name:PARK, SOYUN VICTORIA (DPM)
Entity Type:Individual
Prefix:
First Name:SOYUN
Middle Name:VICTORIA
Last Name:PARK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6628 SOUDER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-2206
Mailing Address - Country:US
Mailing Address - Phone:267-699-6409
Mailing Address - Fax:
Practice Address - Street 1:6628 SOUDER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2206
Practice Address - Country:US
Practice Address - Phone:267-699-6409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006580213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery