Provider Demographics
NPI:1508962812
Name:PARK, SANG T
Entity Type:Individual
Prefix:
First Name:SANG
Middle Name:T
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 1:1 E DRUMBED RD
Mailing Address - Street 2:
Mailing Address - City:VILLAS
Mailing Address - State:NJ
Mailing Address - Zip Code:08251
Mailing Address - Country:US
Mailing Address - Phone:609-886-1126
Mailing Address - Fax:609-889-9464
Practice Address - Street 1:12 FEHERVARI CT
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-6203
Practice Address - Country:US
Practice Address - Phone:609-886-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA34837207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ104627Medicare ID - Type Unspecified
NJC30145Medicare UPIN