Provider Demographics
NPI:1821052630
Name:PARK, JONGSOOK SUSIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JONGSOOK
Middle Name:SUSIE
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12665 GARDEN GROVE BLVD #505
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843
Mailing Address - Country:US
Mailing Address - Phone:714-534-2110
Mailing Address - Fax:714-534-1155
Practice Address - Street 1:12665 GARDEN GROVE BLVD #505
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843
Practice Address - Country:US
Practice Address - Phone:714-534-2110
Practice Address - Fax:714-534-1155
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41515207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C415150Medicaid
CA00C415150Medicaid