Provider Demographics
NPI:1568914273
Name:PARK, DOOSAN
Entity Type:Individual
Prefix:
First Name:DOOSAN
Middle Name:
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 1:1300 S FARMVIEW DR
Mailing Address - Street 2:APT N19
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-3374
Mailing Address - Country:US
Mailing Address - Phone:801-472-7769
Mailing Address - Fax:
Practice Address - Street 1:240 BEISER BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-8208
Practice Address - Country:US
Practice Address - Phone:302-734-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ3-00006342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer