Provider Demographics
NPI:1003855313
Name:PARK, DAVID RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RAE
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 1:10601 WALKER ST
Mailing Address - Street 2:STE 250
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-4733
Mailing Address - Country:US
Mailing Address - Phone:888-499-9303
Mailing Address - Fax:
Practice Address - Street 1:8041 NEWMAN AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647
Practice Address - Country:US
Practice Address - Phone:888-499-9303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG155980207Q00000X
FLME89630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270681400Medicaid
FL48609OtherBCBS
P00223219OtherRAILROAD MEDICARE
FL270681400Medicaid
P00223219OtherRAILROAD MEDICARE
FL48609YMedicare PIN