Provider Demographics
NPI:1730363623
Name:PARK, BOMA (MD)
Entity type:Individual
Prefix:MS
First Name:BOMA
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 1:107 WEST 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550
Mailing Address - Country:US
Mailing Address - Phone:914-699-7200
Mailing Address - Fax:914-699-0837
Practice Address - Street 1:107 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-4002
Practice Address - Country:US
Practice Address - Phone:914-699-7200
Practice Address - Fax:914-699-0837
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003455207R00000X
NY234101172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine