Provider Demographics
NPI:1306814371
Name:PARK, KAY LOREN (MD)
Entity Type:Individual
Prefix:DR
First Name:KAY
Middle Name:LOREN
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:222 W EULALIA ST
Mailing Address - Street 2:STE 110
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2849
Mailing Address - Country:US
Mailing Address - Phone:818-551-7127
Mailing Address - Fax:818-551-7131
Practice Address - Street 1:222 W EULALIA ST
Practice Address - Street 2:STE 110
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2849
Practice Address - Country:US
Practice Address - Phone:818-551-7127
Practice Address - Fax:818-551-7131
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81539207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095000Medicaid
CA00G815390Medicaid
CA1811076342Medicaid
CAWG81539DMedicare ID - Type UnspecifiedMEDICARE PPIN
CA1811076342Medicare PIN
CAG43366Medicare UPIN
CAW16156Medicare ID - Type UnspecifiedMEDICARE GROUP