Provider Demographics
NPI:1801962592
Name:PARK, SUNG HO (DO)
Entity type:Individual
Prefix:
First Name:SUNG
Middle Name:HO
Last Name:PARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92546-0788
Mailing Address - Country:US
Mailing Address - Phone:951-929-6260
Mailing Address - Fax:951-765-2855
Practice Address - Street 1:1415 ROSS AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4306
Practice Address - Country:US
Practice Address - Phone:951-929-6260
Practice Address - Fax:951-765-2855
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A7204207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX72040Medicaid
CAH39929Medicare UPIN
CA00AX72040Medicaid