Basic Information
| Provider Information | |||||||||
| NPI: | 1659484905 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | SOOANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 233 NOSTRAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188265911 | ||||||||
| FaxNumber: | 7188265860 | ||||||||
| Practice Location | |||||||||
| Address1: | 3245 NOSTRAND AVE KINGS HWY CENTER | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186153777 | ||||||||
| FaxNumber: | 7186153481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 120117 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00223383 | 05 | NY | MEDICAID |