Provider Demographics
NPI:1871532309
Name:PARK, GYOUNG J (MD)
Entity type:Individual
Prefix:
First Name:GYOUNG
Middle Name:J
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 1:10 JULIAN
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-2427
Mailing Address - Country:US
Mailing Address - Phone:619-579-8681
Mailing Address - Fax:619-579-0759
Practice Address - Street 1:1685 E MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5225
Practice Address - Country:US
Practice Address - Phone:619-579-8681
Practice Address - Fax:619-579-0759
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
I42774Medicare UPIN