Provider Demographics
NPI:1528226263
Name:PARK, TAE SOON (DPM)
Entity Type:Individual
Prefix:DR
First Name:TAE SOON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:TED
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:1408 SW 170TH ST
Mailing Address - Street 2:
Mailing Address - City:NORMANDY PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98166-3448
Mailing Address - Country:US
Mailing Address - Phone:917-843-2735
Mailing Address - Fax:
Practice Address - Street 1:2950 NORTHUP WAY STE 115
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-1406
Practice Address - Country:US
Practice Address - Phone:425-893-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4895213ES0103X
WAPO 60234756213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery