Provider Demographics
NPI:1184992109
Name:PARK, WONSANG
Entity type:Individual
Prefix:
First Name:WONSANG
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 1:14795 JEFFREY RD STE 104
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-0417
Mailing Address - Country:US
Mailing Address - Phone:949-829-2580
Mailing Address - Fax:949-656-7242
Practice Address - Street 1:14795 JEFFREY RD STE 104
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-0417
Practice Address - Country:US
Practice Address - Phone:949-829-2580
Practice Address - Fax:949-656-7242
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14522171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist