Provider Demographics
NPI:1104825033
Name:PARK, PETER SANG-WOOK (DPM)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:SANG-WOOK
Last Name:PARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 STEIN STRAUSS ST
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-2159
Mailing Address - Country:US
Mailing Address - Phone:714-797-3668
Mailing Address - Fax:
Practice Address - Street 1:1501 W COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-2727
Practice Address - Country:US
Practice Address - Phone:714-410-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4031213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00E40310OtherMEDI CAL
CA1104825033OtherNPI
CACE813AOtherMEDICARE PTAN
CA1104825033OtherNPI