Provider Demographics
NPI:1902806227
Name:PARK, IH KOO (MD)
Entity Type:Individual
Prefix:
First Name:IH
Middle Name:KOO
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 1:100 GROSS CRESCENT CIR
Mailing Address - Street 2:
Mailing Address - City:FT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-3643
Mailing Address - Country:US
Mailing Address - Phone:706-861-7275
Mailing Address - Fax:
Practice Address - Street 1:100 GROSS CRESCENT CIR
Practice Address - Street 2:
Practice Address - City:FT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3643
Practice Address - Country:US
Practice Address - Phone:706-861-7275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15885208600000X
TN8922208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00062059BMedicaid
TN3157184Medicare PIN
GA00062059BMedicaid