Provider Demographics
NPI:1083854293
Name:PATRICK T. PARK M D INC
Entity Type:Organization
Organization Name:PATRICK T. PARK M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-739-1025
Mailing Address - Street 1:266 S HARVARD BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-4373
Mailing Address - Country:US
Mailing Address - Phone:213-739-1025
Mailing Address - Fax:213-739-9936
Practice Address - Street 1:266 S HARVARD BLVD STE 320
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-4373
Practice Address - Country:US
Practice Address - Phone:213-739-1025
Practice Address - Fax:213-739-9936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-27
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76980174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G769800Medicaid
CAF62853Medicare UPIN
CA5548030Medicare PIN