Provider Demographics
NPI:1699093385
Name:PARK, DONG H (LAC)
Entity type:Individual
Prefix:MR
First Name:DONG
Middle Name:H
Last Name:PARK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16307 DEPOT RD STE S-2
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2050
Mailing Address - Country:US
Mailing Address - Phone:718-644-6101
Mailing Address - Fax:
Practice Address - Street 1:16307 DEPOT RD STE S-2
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-2050
Practice Address - Country:US
Practice Address - Phone:718-644-6101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000362171100000X
NY002992171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist