Provider Demographics
NPI:1184160350
Name:PARK, JUNGSANG
Entity type:Individual
Prefix:MR
First Name:JUNGSANG
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:PMB 731 BOX 10001
Mailing Address - Street 2:MIDDLE RD, GUALORAI
Mailing Address - City:SAIPAN
Mailing Address - State:MP
Mailing Address - Zip Code:96950
Mailing Address - Country:US
Mailing Address - Phone:670-234-7674
Mailing Address - Fax:
Practice Address - Street 1:PMB 731 BOX 10001
Practice Address - Street 2:MIDDLE RD
Practice Address - City:SAIPAN
Practice Address - State:MP
Practice Address - Zip Code:96950-8901
Practice Address - Country:US
Practice Address - Phone:670-234-7674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MP0030171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist