Provider Demographics
NPI:1396841961
Name:PARK, VERNON GUY (MD)
Entity Type:Individual
Prefix:DR
First Name:VERNON
Middle Name:GUY
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 1:2200 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-2004
Mailing Address - Country:US
Mailing Address - Phone:209-667-1606
Mailing Address - Fax:209-667-4685
Practice Address - Street 1:2200 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2004
Practice Address - Country:US
Practice Address - Phone:209-667-1606
Practice Address - Fax:209-667-4685
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS654218Medicaid
G325410Medicare ID - Type Unspecified
CAS654218Medicaid