Provider Demographics
NPI:1801845946
Name:PARK, JOUNG HO (MD)
Entity Type:Individual
Prefix:
First Name:JOUNG
Middle Name:HO
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:25710 KELLY RD
Mailing Address - Street 2:STE 3
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066
Mailing Address - Country:US
Mailing Address - Phone:586-772-2600
Mailing Address - Fax:586-772-5289
Practice Address - Street 1:25710 KELLY RD
Practice Address - Street 2:STE 3
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066
Practice Address - Country:US
Practice Address - Phone:586-772-2600
Practice Address - Fax:586-772-5289
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI034719207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1390410Medicaid
A78110Medicare UPIN
MI1390410Medicaid