Provider Demographics
NPI:1497869499
Name:PARK, YONG HO
Entity Type:Individual
Prefix:DR
First Name:YONG
Middle Name:HO
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 WEST RIVERSIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:MT
Mailing Address - Zip Code:59872-0847
Mailing Address - Country:US
Mailing Address - Phone:406-822-3307
Mailing Address - Fax:406-822-3308
Practice Address - Street 1:501 WEST RIVERSIDE AVENUE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:MT
Practice Address - Zip Code:59872-0847
Practice Address - Country:US
Practice Address - Phone:406-822-3307
Practice Address - Fax:406-822-3308
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4555208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1014752Medicaid
MT0023673Medicaid
MT01-1213-7OtherSTATE FUND-DIV OF W/C
MT0023673Medicaid