Provider Demographics
NPI:1801996962
Name:PARK, BYUNG-GOOK (MD)
Entity type:Individual
Prefix:
First Name:BYUNG-GOOK
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 WATER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4114
Mailing Address - Country:US
Mailing Address - Phone:831-423-8753
Mailing Address - Fax:831-425-3878
Practice Address - Street 1:100 OCONNOR DR STE 11
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1638
Practice Address - Country:US
Practice Address - Phone:408-885-0807
Practice Address - Fax:831-425-3878
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88228207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A882280Medicaid
CA00A882280Medicaid
CAZZZ02797ZMedicare PIN
CA00A882280Medicare PIN
CA00A882280Medicare PIN