Provider Demographics
NPI:1285669085
Name:PARK, TARI Y (MD)
Entity Type:Individual
Prefix:DR
First Name:TARI
Middle Name:Y
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:YOUNG
Other - Middle Name:JU
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4800
Mailing Address - Country:US
Mailing Address - Phone:858-636-4300
Mailing Address - Fax:858-636-4319
Practice Address - Street 1:250 E CHASE AVE
Practice Address - Street 2:108
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-6305
Practice Address - Country:US
Practice Address - Phone:619-442-2560
Practice Address - Fax:619-442-7836
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74537208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA74537OtherMD LICENSE