Provider Demographics
NPI:1609141373
Name:PARK, SAE-LYOUNG (DPM)
Entity Type:Individual
Prefix:DR
First Name:SAE-LYOUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143-08 ROOSEVELT AVE.
Mailing Address - Street 2:APT L4
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354
Mailing Address - Country:US
Mailing Address - Phone:718-939-3220
Mailing Address - Fax:718-939-3440
Practice Address - Street 1:143-08 ROOSEVELT AVE.
Practice Address - Street 2:APT L4
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:718-939-3220
Practice Address - Fax:718-939-3440
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006468213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03581459Medicaid
NY1609141373OtherMEDICARE