Provider Demographics
NPI:1164582656
Name:PARK, SANGDO (MD)
Entity Type:Individual
Prefix:
First Name:SANGDO
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 BEVERLY BLVD
Mailing Address - Street 2:SUITE 223
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2216
Mailing Address - Country:US
Mailing Address - Phone:213-989-0644
Mailing Address - Fax:
Practice Address - Street 1:2105 BEVERLY BLVD
Practice Address - Street 2:SUITE 223
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2216
Practice Address - Country:US
Practice Address - Phone:213-989-0644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6562207XX0005X
CAA107642207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8W9051OtherBCBS
TX8CR159OtherBC/BS TX - EFFECT. 02/01/2011
TXP00935331OtherRAILROAD MEDICARE
TXTXB126770Medicare PIN
TX8CR159OtherBC/BS TX - EFFECT. 02/01/2011