Provider Demographics
NPI:1659484905
Name:PARK, SOOANN (MD)
Entity Type:Individual
Prefix:
First Name:SOOANN
Middle Name:
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 1:233 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205
Mailing Address - Country:US
Mailing Address - Phone:718-826-5911
Mailing Address - Fax:718-826-5860
Practice Address - Street 1:3245 NOSTRAND AVE KINGS HWY CENTER
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229
Practice Address - Country:US
Practice Address - Phone:718-615-3777
Practice Address - Fax:718-615-3481
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120117207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00223383Medicaid
NY00223383Medicaid
68364100Medicare ID - Type Unspecified