Provider Demographics
NPI:1083645832
Name:PARK, JOE (MD)
Entity Type:Individual
Prefix:
First Name:JOE
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 1:15447 W SAND ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2904
Mailing Address - Country:US
Mailing Address - Phone:760-843-9679
Mailing Address - Fax:760-245-3618
Practice Address - Street 1:15447 W SAND ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2904
Practice Address - Country:US
Practice Address - Phone:760-843-9679
Practice Address - Fax:760-245-3618
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86588207LP2900X, 208VP0014X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A865880Medicaid
CA00A865880Medicaid
I16538Medicare UPIN
CA00A865880Medicaid