Provider Demographics
NPI:1871704916
Name:PARK, KYUNG SOOK (OMD)
Entity type:Individual
Prefix:
First Name:KYUNG
Middle Name:SOOK
Last Name:PARK
Suffix:
Gender:F
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4706 NATHAN HALE DR APT 304
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-4985
Mailing Address - Country:US
Mailing Address - Phone:703-303-2915
Mailing Address - Fax:
Practice Address - Street 1:4706 NATHAN HALE DR APT 304
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-4985
Practice Address - Country:US
Practice Address - Phone:703-303-2915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000462171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist