Provider Demographics
NPI:1285984120
Name:PARK, SANDRA SUNGJU
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:SUNGJU
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WATERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE FERRY
Mailing Address - State:NJ
Mailing Address - Zip Code:07643-2208
Mailing Address - Country:US
Mailing Address - Phone:201-741-7578
Mailing Address - Fax:
Practice Address - Street 1:103 WATERSIDE DR
Practice Address - Street 2:
Practice Address - City:LITTLE FERRY
Practice Address - State:NJ
Practice Address - Zip Code:07643-2208
Practice Address - Country:US
Practice Address - Phone:201-741-7578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00277700225700000X
NJ25MZ00092100171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist