Provider Demographics
NPI:1407988165
Name:PARK, AGATHA L (MD)
Entity Type:Individual
Prefix:DR
First Name:AGATHA
Middle Name:L
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 S CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-4001
Mailing Address - Country:US
Mailing Address - Phone:310-550-7669
Mailing Address - Fax:310-247-0950
Practice Address - Street 1:245 S CRESCENT DR
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-4001
Practice Address - Country:US
Practice Address - Phone:310-550-7669
Practice Address - Fax:310-247-0950
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95-4263002174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA10818Medicare UPIN