Basic Information
| Provider Information | |||||||||
| NPI: | 1295932242 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | SANGKYU | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S HENDERSON ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174131500 | ||||||||
| FaxNumber: | 8174131499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0203X | BP10022820 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0001X | N3228 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | P00764078 | 01 | TX | RAILROAD MEDICARE | OTHER | 8CA240 | 01 | TX | BLUECROSS BLUESHIELD OF TEXAS | OTHER | 202476201 | 05 | TX | MEDICAID | 202476202 | 05 | TX | MEDICAID |