Provider Demographics
NPI:1427256635
Name:PARK, KYONG (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:KYONG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 514
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-0514
Mailing Address - Country:US
Mailing Address - Phone:518-285-0864
Mailing Address - Fax:
Practice Address - Street 1:360 BINNEY ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02142-1011
Practice Address - Country:US
Practice Address - Phone:571-353-0256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8207207Q00000X
VA01012445362083P0901X
NY2536552083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine