Provider Demographics
NPI:1437335361
Name:PARK, KITAE KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KITAE
Middle Name:KEVIN
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:PO BOX 845833
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-5833
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:2251 W ROSECRANS AVE STE 21
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90222-3860
Practice Address - Country:US
Practice Address - Phone:424-529-6755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC56093207R00000X, 207RC0200X, 207RP1001X
HI16037207RC0200X, 207RP1001X
CAA56093207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease