Provider Demographics
NPI:1508918616
Name:PARK, BRIAN DUKE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DUKE
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 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2725 CAPITOL AVE DEPT 402
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6032
Practice Address - Country:US
Practice Address - Phone:916-262-9400
Practice Address - Fax:916-262-9399
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 1153502086S0129X
CAA972472086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14QW7OtherBLUE CROSS BLUE SHIELD
FL009175600Medicaid
FLP01221852Medicare PIN
FL14QW7OtherBLUE CROSS BLUE SHIELD