Provider Demographics
NPI:1902887771
Name:PARK, JOON (MD)
Entity Type:Individual
Prefix:DR
First Name:JOON
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:PO BOX 5865
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-5865
Mailing Address - Country:US
Mailing Address - Phone:806-743-2898
Mailing Address - Fax:806-743-2787
Practice Address - Street 1:3502 9TH ST
Practice Address - Street 2:SUITE 290
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-3300
Practice Address - Country:US
Practice Address - Phone:806-743-1540
Practice Address - Fax:806-743-3908
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE99042080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44268OtherPRESBYTERIAN COMMERCIAL
NM44268Medicaid
TX85E551OtherBC/BS
NMA078OtherTRIWEST
NMV3884Medicaid
TX80896ZOtherHMO BLUE
TXE79704Medicare UPIN
TX85E551OtherBC/BS