Provider Demographics
NPI:1033678305
Name:PARK, ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
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 1:11645 WILSHIRE BLVD STE 900
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6811
Mailing Address - Country:US
Mailing Address - Phone:424-243-7668
Mailing Address - Fax:213-408-4414
Practice Address - Street 1:11645 WILSHIRE BLVD STE 900
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6811
Practice Address - Country:US
Practice Address - Phone:424-243-7668
Practice Address - Fax:213-408-4414
Is Sole Proprietor?:No
Enumeration Date:2019-03-17
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA188055207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology