Basic Information
Provider Information | |||||||||
NPI: | 1689601239 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARK | ||||||||
FirstName: | YON | ||||||||
MiddleName: | KYU | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PARK | ||||||||
OtherFirstName: | Y.K. PETER | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 102222 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303682222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2392748200 | ||||||||
FaxNumber: | 2392783350 | ||||||||
Practice Location | |||||||||
Address1: | 3402 W DR MARTIN LUTHER KING JR BLVD | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336076214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138753950 | ||||||||
FaxNumber: | 8138722741 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2006 | ||||||||
LastUpdateDate: | 08/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | ME70095 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 260435300 | 05 | FL |   | MEDICAID | P00679543 | 01 | FL | RR MEDICARE | OTHER | 41655 | 01 | FL | BCBS | OTHER |