Provider Demographics
NPI:1376924373
Name:PARK, BUMSOO (MD)
Entity type:Individual
Prefix:
First Name:BUMSOO
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 HICKSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-3471
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 W 31ST ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-2861
Practice Address - Country:US
Practice Address - Phone:646-987-3436
Practice Address - Fax:646-293-1441
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301108105207Q00000X
NY336914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine