Basic Information
| Provider Information | |||||||||
| NPI: | 1780760132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | HO-HYUN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PARK | ||||||||
| OtherFirstName: | HO | ||||||||
| OtherMiddleName: | H. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1322 SUSQUEHANNA RD | ||||||||
| Address2: | |||||||||
| City: | RYDAL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190461827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155725404 | ||||||||
| FaxNumber: | 2155721184 | ||||||||
| Practice Location | |||||||||
| Address1: | 521 PLYMOUTH RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194621638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109413390 | ||||||||
| FaxNumber: | 6109413391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2006 | ||||||||
| LastUpdateDate: | 12/18/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | MD-031306-L | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 654087 | 05 | PA | MEDICAID |