Provider Demographics
NPI:1528009859
Name:PARK, UI HO (MD)
Entity Type:Individual
Prefix:DR
First Name:UI
Middle Name:HO
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3889 COBB PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4084
Mailing Address - Country:US
Mailing Address - Phone:770-975-1299
Mailing Address - Fax:770-975-1361
Practice Address - Street 1:3889 COBB PKWY NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4084
Practice Address - Country:US
Practice Address - Phone:770-975-1299
Practice Address - Fax:770-975-1361
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018938174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI43817Medicare UPIN
GA02BDHZCMedicare PIN