Provider Demographics
NPI:1700537305
Name:PARK, SUNG
Entity type:Individual
Prefix:
First Name:SUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10999 RIVERSIDE DR STE 306
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2239
Mailing Address - Country:US
Mailing Address - Phone:818-824-3702
Mailing Address - Fax:
Practice Address - Street 1:10999 RIVERSIDE DR STE 306
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602-2239
Practice Address - Country:US
Practice Address - Phone:818-824-3702
Practice Address - Fax:818-824-3712
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51126207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1992134696Medicaid