Provider Demographics
NPI:1003839002
Name:PARK, JOONG Y (MD)
Entity Type:Individual
Prefix:
First Name:JOONG
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 1:3511 W OLYMPIC BL
Mailing Address - Street 2:#101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019
Mailing Address - Country:US
Mailing Address - Phone:323-766-1057
Mailing Address - Fax:323-766-8790
Practice Address - Street 1:3511 W OLYMPIC BL
Practice Address - Street 2:#101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019
Practice Address - Country:US
Practice Address - Phone:323-766-1057
Practice Address - Fax:323-766-8790
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39059208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A390590Medicaid
CA00A390590Medicaid