Provider Demographics
NPI:1093823494
Name:PARK, KEVIN S (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:11411 BROOKSHIRE AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-5004
Mailing Address - Country:US
Mailing Address - Phone:562-869-4421
Mailing Address - Fax:562-869-3600
Practice Address - Street 1:11525 BROOKSHIRE AVE
Practice Address - Street 2:SUITE #201
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4985
Practice Address - Country:US
Practice Address - Phone:562-869-4421
Practice Address - Fax:562-869-3600
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2016-01-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA67776207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G98129Medicare UPIN
A67776Medicare ID - Type Unspecified