Provider Demographics
NPI:1760582712
Name:PARK, YONG D (MD)
Entity Type:Individual
Prefix:
First Name:YONG
Middle Name:D
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 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2650
Mailing Address - Country:US
Mailing Address - Phone:706-828-6410
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH STREET
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912
Practice Address - Country:US
Practice Address - Phone:706-721-3371
Practice Address - Fax:706-721-3377
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0351142084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000473459AMedicaid
SCG07909Medicaid
GA000473459AMedicaid
GA13BDBQVMedicare ID - Type UnspecifiedGA MEDICARE