Provider Demographics
NPI:1528140928
Name:PARK, SUSANNA JUNG-A (MD)
Entity type:Individual
Prefix:DR
First Name:SUSANNA
Middle Name:JUNG-A
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSANNA
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11515 EL CAMINO REAL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2045
Mailing Address - Country:US
Mailing Address - Phone:858-794-6363
Mailing Address - Fax:
Practice Address - Street 1:11515 EL CAMINO REAL
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2045
Practice Address - Country:US
Practice Address - Phone:858-794-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54916174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist