Provider Demographics
NPI:1306185285
Name:JUSTINE PARK, MD, INC.
Entity Type:Organization
Organization Name:JUSTINE PARK, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-246-4936
Mailing Address - Street 1:435 ARDEN AVE STE 435
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-4044
Mailing Address - Country:US
Mailing Address - Phone:818-246-4936
Mailing Address - Fax:818-246-4937
Practice Address - Street 1:435 ARDEN AVE STE 435
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-4044
Practice Address - Country:US
Practice Address - Phone:818-246-4936
Practice Address - Fax:818-246-4937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88512207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty