Provider Demographics
NPI:1609819226
Name:PARK, SOO H (MD)
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:H
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 1:5580 TREELINE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-4050
Mailing Address - Country:US
Mailing Address - Phone:217-979-1165
Mailing Address - Fax:
Practice Address - Street 1:5580 TREELINE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-4050
Practice Address - Country:US
Practice Address - Phone:217-979-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD153728207RI0011X
IL036042861207RI0011X
IN01064126A207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000984930OtherANTHEM PIN
IN200031190Medicaid
E47884Medicare UPIN
ININ1436009Medicare PIN
IN200031190Medicaid
ININ1437009Medicare PIN