Provider Demographics
NPI:1023394665
Name:PARK, JOHN MOONKEUN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MOONKEUN
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 1:17404 BURKE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-2242
Mailing Address - Country:US
Mailing Address - Phone:351-466-4260
Mailing Address - Fax:
Practice Address - Street 1:17404 BURKE ST STE 102
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2242
Practice Address - Country:US
Practice Address - Phone:531-466-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.095909208600000X, 2086S0129X
IA405632086S0129X
NE265092086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025724800Medicaid
NE10026135100Medicaid
IA1023394665Medicaid
NE47068731713Medicaid
NE10026454700Medicaid
IA1023394665Medicaid
NE099099160Medicare PIN