Provider Demographics
NPI:1659418382
Name:PARK, HYUNG DONG (MD)
Entity Type:Individual
Prefix:
First Name:HYUNG
Middle Name:DONG
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:PO BOX 602530
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2530
Mailing Address - Country:US
Mailing Address - Phone:910-642-1776
Mailing Address - Fax:910-642-9305
Practice Address - Street 1:500 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472
Practice Address - Country:US
Practice Address - Phone:910-642-1776
Practice Address - Fax:910-642-9305
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047265207R00000X
NC2009-01534207R00000X
ORMD27189208M00000X
NY285118207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1659418382Medicaid
NC2075226CMedicare PIN
NCNC4035FMedicare PIN
NCNC7539BMedicare PIN
NCNC7539CMedicare PIN
NCNC4035DMedicare PIN
NC2075226DMedicare PIN
NC2085226AMedicare PIN
NCNC7539D238Medicare PIN
NCNC7539C238Medicare PIN
NC1659418382Medicaid
NC2075226Medicare PIN
NCNC4035EMedicare PIN