Provider Demographics
NPI:1659951788
Name:PARK, SO MYUNG (DO)
Entity Type:Individual
Prefix:
First Name:SO MYUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 BURGUNDY TRL
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-6727
Mailing Address - Country:US
Mailing Address - Phone:214-830-9023
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO MSC10 5550
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-6331
Practice Address - Fax:505-272-0475
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program