Provider Demographics
NPI:1932291432
Name:PARK-DAVIS, SUNGNAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNGNAN
Middle Name:
Last Name:PARK-DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30880 BECK RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1000
Mailing Address - Country:US
Mailing Address - Phone:248-926-0009
Mailing Address - Fax:248-956-9198
Practice Address - Street 1:30880 BECK RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1000
Practice Address - Country:US
Practice Address - Phone:248-926-0009
Practice Address - Fax:248-956-9198
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076848208000000X, 207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4675192Medicaid
MI4675192Medicaid
MIN89750002Medicare ID - Type Unspecified