Provider Demographics
NPI:1952070773
Name:PARK, SOOBYUNG (MD)
Entity type:Individual
Prefix:
First Name:SOOBYUNG
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 1:18511 HIGHLANDER MEDICS WBAMC/DOM/IM TRAINING PROGRAM
Mailing Address - Street 2:EAST CLINIC ROOM 4370
Mailing Address - City:FT. BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79918
Mailing Address - Country:US
Mailing Address - Phone:915-742-0399
Mailing Address - Fax:915-742-4902
Practice Address - Street 1:UNIT 15245
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271-5245
Practice Address - Country:US
Practice Address - Phone:860-716-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE35480207R00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine