Provider Demographics
NPI:1902948193
Name:PARK, SEOUNG SOU (MD)
Entity Type:Individual
Prefix:
First Name:SEOUNG
Middle Name:SOU
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 1:105 STEVENS AVENUE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2686
Mailing Address - Country:US
Mailing Address - Phone:914-663-6635
Mailing Address - Fax:914-663-6637
Practice Address - Street 1:105 STEVENS AVENUE
Practice Address - Street 2:SUITE 310
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2686
Practice Address - Country:US
Practice Address - Phone:914-663-6635
Practice Address - Fax:914-663-6637
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197192207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
P1229667OtherOXFORD HEALTH PLAN
NY21N461OtherEMPIRE BCBS
7464117OtherAETNA
NY01729675Medicaid
P1229667OtherOXFORD HEALTH PLAN
G45574Medicare UPIN