Provider Demographics
NPI:1295932242
Name:PARK, CLINTON SANGKYU (MD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:SANGKYU
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:500 S HENDERSON ST STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2154
Practice Address - Country:US
Practice Address - Phone:817-413-1500
Practice Address - Fax:817-413-1499
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP100228202085R0203X
TXN32282085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00764078OtherRAILROAD MEDICARE
TX8CA240OtherBLUECROSS BLUESHIELD OF TEXAS
TX202476201Medicaid
TX202476202Medicaid
TX202476202Medicaid
TX8L14025Medicare PIN