Provider Demographics
NPI:1063560597
Name:PARK, JOHN JUNGSIK (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JUNGSIK
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16605 SOUTHWEST FWY
Mailing Address - Street 2:SUITE 285
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-3501
Mailing Address - Country:US
Mailing Address - Phone:281-313-0031
Mailing Address - Fax:
Practice Address - Street 1:16605 SOUTHWEST FWY
Practice Address - Street 2:SUITE 285
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-3501
Practice Address - Country:US
Practice Address - Phone:281-313-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXN2712207T00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BZ837OtherBLUE CROSS BLUE SHIELD TEXAS
TX202947201Medicaid