Provider Demographics
NPI:1508023664
Name:PARK, BONG KWAN (DOM)
Entity Type:Individual
Prefix:DR
First Name:BONG KWAN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14471 S. DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176
Mailing Address - Country:US
Mailing Address - Phone:213-700-0042
Mailing Address - Fax:786-573-4777
Practice Address - Street 1:14471 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-7924
Practice Address - Country:US
Practice Address - Phone:213-700-0042
Practice Address - Fax:786-573-4777
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10718171100000X
FLAP 3556171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist