Provider Demographics
NPI:1154465631
Name:PETER PARK MD INC
Entity Type:Organization
Organization Name:PETER PARK MD INC
Other - Org Name:NEW SUNRISE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:TAKAYUKI
Authorized Official - Last Name:ARAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-388-2772
Mailing Address - Street 1:PO BOX 27206
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-0206
Mailing Address - Country:US
Mailing Address - Phone:213-385-0675
Mailing Address - Fax:213-365-6429
Practice Address - Street 1:2600 W PICO BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-3902
Practice Address - Country:US
Practice Address - Phone:213-388-2772
Practice Address - Fax:213-388-2112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA54976Medicare ID - Type UnspecifiedM.D.