Provider Demographics
NPI:1457643215
Name:PARK, KENNETH J (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 ORANGE TREE LN
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4501
Mailing Address - Country:US
Mailing Address - Phone:909-786-0725
Mailing Address - Fax:
Practice Address - Street 1:2 W FERN AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373
Practice Address - Country:US
Practice Address - Phone:909-793-3311
Practice Address - Fax:805-354-7102
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14077207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB243726OtherMEDICARE ID