Basic Information
| Provider Information | |||||||||
| NPI: | 1568404481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | HYUNGWOOK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9724379605 | ||||||||
| Practice Location | |||||||||
| Address1: | 2790 LAKE VISTA DR | ||||||||
| Address2: | |||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750673884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724591300 | ||||||||
| FaxNumber: | 9724591382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 01/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | J8708 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 8R1520 | 01 | TX | BLUE CROSS OF TEXAS | OTHER | 129006605 | 05 | TX | MEDICAID | 129006603 | 05 | TX | MEDICAID | 129006604 | 05 | TX | MEDICAID |