Provider Demographics
NPI:1063578961
Name:PARK, JOHN KYUN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KYUN
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 1:2601 LAKE DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6688
Mailing Address - Country:US
Mailing Address - Phone:919-782-5911
Mailing Address - Fax:
Practice Address - Street 1:2601 LAKE DR
Practice Address - Street 2:SUITE 301
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6688
Practice Address - Country:US
Practice Address - Phone:919-782-5911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00439207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD40813Medicare UPIN