Provider Demographics
NPI:1902337793
Name:PARK, KEON MIN (MD)
Entity Type:Individual
Prefix:
First Name:KEON MIN
Middle Name:
Last Name:PARK
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 1:513 PARNASSUS AVENUE, S-321
Mailing Address - Street 2:UCSF - DEPARTMENT OF SURGERY
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:93132-0470
Mailing Address - Country:US
Mailing Address - Phone:415-476-1239
Mailing Address - Fax:
Practice Address - Street 1:513 PARNASSUS AVENUE, S-321
Practice Address - Street 2:UCSF - DEPARTMENT OF SURGERY
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:93132-0470
Practice Address - Country:US
Practice Address - Phone:415-476-1239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA160755208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program