Provider Demographics
NPI:1174512735
Name:PARK, HYOUNGSUP (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:HYOUNGSUP
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:DR
Other - First Name:H
Other - Middle Name:STEPHEN
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:599 FAMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032
Mailing Address - Country:US
Mailing Address - Phone:608-284-4945
Mailing Address - Fax:860-284-4946
Practice Address - Street 1:599 FAMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032
Practice Address - Country:US
Practice Address - Phone:608-284-4945
Practice Address - Fax:860-284-4946
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223132207Q00000X
LA200492207Q00000X
CT043254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008004410Medicaid
CT008004410Medicaid
CT008004410Medicaid