Provider Demographics
NPI:1043292998
Name:PARK, WOOSUP MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:WOOSUP
Middle Name:MICHAEL
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5880 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-8220
Mailing Address - Country:US
Mailing Address - Phone:515-633-3835
Mailing Address - Fax:515-633-3838
Practice Address - Street 1:5880 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8220
Practice Address - Country:US
Practice Address - Phone:515-633-3600
Practice Address - Fax:515-288-0840
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA355612086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0432393Medicaid
IACD4547OtherRAILROAD MEDICARE GROUP #
IAP00110411OtherRAILROAD MEDICARE
IACD4547OtherRAILROAD MEDICARE GROUP #
IAH17775Medicare UPIN