Provider Demographics
NPI:1912297516
Name:PARK, DONG SOON (DC)
Entity Type:Individual
Prefix:
First Name:DONG
Middle Name:SOON
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4569 PARSONS BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-2253
Mailing Address - Country:US
Mailing Address - Phone:563-209-3619
Mailing Address - Fax:
Practice Address - Street 1:7003 FORT HAMILTON PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-1103
Practice Address - Country:US
Practice Address - Phone:718-333-5603
Practice Address - Fax:718-333-5604
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2012-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010548, AJ010340111N00000X
IA007077111N00000X
NY011699-1111N00000X
IL038011972111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor