Provider Demographics
NPI:1053607952
Name:PARK, SAMUEL JOON (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JOON
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 1:160 1ST ST UNIT 551
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-5025
Mailing Address - Country:US
Mailing Address - Phone:516-619-8098
Mailing Address - Fax:
Practice Address - Street 1:160 1ST ST UNIT 551
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-5025
Practice Address - Country:US
Practice Address - Phone:516-619-8098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01081067A207R00000X
WV28444207R00000X
NY285562208000000X, 207R00000X
COCDRH.0057133208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics