Provider Demographics
NPI:1063296150
Name:PARK, SANGWOOK
Entity type:Individual
Prefix:
First Name:SANGWOOK
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 1:3381 BLACKBURN ST APT 1306
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-1590
Mailing Address - Country:US
Mailing Address - Phone:469-381-9537
Mailing Address - Fax:
Practice Address - Street 1:3381 BLACKBURN ST APT 1306
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-1590
Practice Address - Country:US
Practice Address - Phone:469-381-9537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program