1710354907 NPI number — MIJEONG PARK CPNP

Table of content: MIJEONG PARK CPNP (NPI 1710354907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710354907 NPI number — MIJEONG PARK CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
MIJEONG
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710354907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27721 STATE HIGHWAY 249 STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOMBALL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77375-6579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-357-5115
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12015 LOUETTA RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77070-1148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-664-2152
Provider Business Practice Location Address Fax Number:
281-257-3514
Provider Enumeration Date:
08/24/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  5007911 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: AP135474 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1579732 . This is a "WELLPATH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1710354907 . This is a "HUMANA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1710354907 . This is a "DOCTORS DIRECT" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1710354907 . This is a "HEALTHNET FEDERAL SERVICES" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 298447 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 4632274 . This is a "COVENTRY NATIONAL - COVENTRY PPO" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: FH4002315 . This is a "FIRST CAROLINA CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1579732 . This is a "COVENTRY OF THE CAROLINAS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1710354907 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4948746 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 135452367 . This is a "PHCS/MULTIPLAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1710354907 . This is a "HEALTHSMART" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1710354907 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19EFK . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3455644 . This is a "CIGNA/GREATWEST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5707800 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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