Provider Demographics
NPI:1689635880
Name:PARK, KWANG-SOO (MD)
Entity Type:Individual
Prefix:
First Name:KWANG-SOO
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 1:1065 NE 125TH ST STE 409
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5834
Mailing Address - Country:US
Mailing Address - Phone:888-852-6672
Mailing Address - Fax:877-720-0502
Practice Address - Street 1:6915 TUTT BLVD STE 110B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923
Practice Address - Country:US
Practice Address - Phone:719-445-1292
Practice Address - Fax:719-591-6486
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00606752084P0800X
CODR00606752084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2334978Medicaid
WV1840930000Medicaid
WV4087512Medicare ID - Type Unspecified
OH2334978Medicaid