Provider Demographics
NPI:1689680019
Name:PAK, SANG I (MD)
Entity Type:Individual
Prefix:
First Name:SANG
Middle Name:I
Last Name:PAK
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 5545
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11802-5545
Mailing Address - Country:US
Mailing Address - Phone:631-283-2430
Mailing Address - Fax:631-283-7496
Practice Address - Street 1:240 MEETING HOUSE LANE
Practice Address - Street 2:SURGICAL SPECIALTIES OFFICE
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968
Practice Address - Country:US
Practice Address - Phone:631-726-8717
Practice Address - Fax:631-726-8720
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208286208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01925662Medicaid
NY01925662Medicaid
NY03299Medicare ID - Type Unspecified