Provider Demographics
NPI:1508493008
Name:PARK, JONG HYUN
Entity Type:Individual
Prefix:
First Name:JONG
Middle Name:HYUN
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:PO BOX 2352
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90632-2352
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-1001
Practice Address - Country:US
Practice Address - Phone:323-409-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA186433208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program