Provider Demographics
NPI:1104014034
Name:JOONG YOUNG PARK M.D. INC.
Entity Type:Organization
Organization Name:JOONG YOUNG PARK M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOONG YOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-534-1112
Mailing Address - Street 1:9535 GARDEN GROVE BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1551
Mailing Address - Country:US
Mailing Address - Phone:714-534-1112
Mailing Address - Fax:714-534-1116
Practice Address - Street 1:9535 GARDEN GROVE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1551
Practice Address - Country:US
Practice Address - Phone:714-534-1112
Practice Address - Fax:714-534-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39059208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A390590Medicaid
CA00A390590Medicaid
CAW21586Medicare PIN