Provider Demographics
NPI:1750353124
Name:PARK, BUM Y (MD)
Entity type:Individual
Prefix:
First Name:BUM
Middle Name:Y
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 1:4010 70TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2930
Mailing Address - Country:US
Mailing Address - Phone:718-899-4600
Mailing Address - Fax:718-446-8302
Practice Address - Street 1:4010 70TH ST
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-2930
Practice Address - Country:US
Practice Address - Phone:718-899-4600
Practice Address - Fax:718-446-8302
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168409208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01008740Medicaid
NY01008740Medicaid
02350Medicare ID - Type Unspecified