Provider Demographics
NPI:1336967611
Name:LIGHTHOUSE PEDIATRIC MEDICINE PLLC
Entity type:Organization
Organization Name:LIGHTHOUSE PEDIATRIC MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER, PHYSICIAN, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-243-3599
Mailing Address - Street 1:1505 NW GILMAN BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5398
Mailing Address - Country:US
Mailing Address - Phone:425-243-3599
Mailing Address - Fax:
Practice Address - Street 1:1505 NW GILMAN BLVD STE 8
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5398
Practice Address - Country:US
Practice Address - Phone:425-243-3599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty