Provider Demographics
NPI:1528565371
Name:PARK, SOO YEUN
Entity Type:Individual
Prefix:
First Name:SOO YEUN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 W IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3812
Mailing Address - Country:US
Mailing Address - Phone:714-449-6900
Mailing Address - Fax:
Practice Address - Street 1:955 W IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3812
Practice Address - Country:US
Practice Address - Phone:714-449-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A17740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine