Provider Demographics
NPI:1952070773
Name:PARK, SOOBYUNG
Entity Type:Individual
Prefix:
First Name:SOOBYUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18511 HIGHLANDER MEDICS WBAMC/DOM/IM TRAINING PROGRAM
Mailing Address - Street 2:EAST CLINIC ROOM 4370
Mailing Address - City:FT. BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79918
Mailing Address - Country:US
Mailing Address - Phone:915-742-0399
Mailing Address - Fax:915-742-4902
Practice Address - Street 1:18511 HIGHLANDER MEDICS WBAMC/DOM/IM TRAINING PROGRAM
Practice Address - Street 2:EAST CLINIC ROOM 4370
Practice Address - City:FT. BLISS
Practice Address - State:TX
Practice Address - Zip Code:79918
Practice Address - Country:US
Practice Address - Phone:915-742-0399
Practice Address - Fax:915-742-4902
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program