Provider Demographics
NPI:1609249960
Name:PARK, KYUNG WON (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:KYUNG WON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W 46TH ST STE 811
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-4549
Mailing Address - Country:US
Mailing Address - Phone:718-414-5207
Mailing Address - Fax:929-224-0712
Practice Address - Street 1:2 W 46TH ST STE 811
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-4549
Practice Address - Country:US
Practice Address - Phone:718-414-5207
Practice Address - Fax:929-224-0712
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034904225100000X, 2251G0304X, 2251P0200X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports