Provider Demographics
NPI:1568454049
Name:PARK, KYUNG SOON (MD)
Entity type:Individual
Prefix:MR
First Name:KYUNG
Middle Name:SOON
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 1:575 COAL VALLEY ROAD
Mailing Address - Street 2:SUITE 504
Mailing Address - City:CLAIRTON
Mailing Address - State:PA
Mailing Address - Zip Code:15025-3729
Mailing Address - Country:US
Mailing Address - Phone:412-469-7900
Mailing Address - Fax:412-469-7919
Practice Address - Street 1:575 COAL VALLEY ROAD
Practice Address - Street 2:SUITE 504
Practice Address - City:CLAIRTON
Practice Address - State:PA
Practice Address - Zip Code:15025-3729
Practice Address - Country:US
Practice Address - Phone:412-469-7900
Practice Address - Fax:412-469-7919
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067920L174400000X
PAMD-067920-L208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017467910002Medicaid
G90164Medicare UPIN
PA0017467910002Medicaid
PA026065QTZMedicare PIN