Provider Demographics
NPI:1801423157
Name:PARK, KWANGWON (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:KWANGWON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N 84TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4101
Mailing Address - Country:US
Mailing Address - Phone:402-955-6329
Mailing Address - Fax:402-955-6529
Practice Address - Street 1:111 N 84TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4101
Practice Address - Country:US
Practice Address - Phone:402-955-6329
Practice Address - Fax:202-877-8959
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE35792207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic SurgeryGroup - Single Specialty