Provider Demographics
NPI:1962759365
Name:PARK, JONGDUG
Entity type:Individual
Prefix:
First Name:JONGDUG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 LARCHMONT ACRES APT A
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-7378
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:826 LARCHMONT ACRES APT A
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-7378
Practice Address - Country:US
Practice Address - Phone:917-715-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012153111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor