Provider Demographics
NPI:1518197938
Name:PARK, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 DOUGLAS BLVD., SUITE 405
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95611
Mailing Address - Country:US
Mailing Address - Phone:847-337-9051
Mailing Address - Fax:
Practice Address - Street 1:3300 DOUGLAS BLVD STE 405
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3841
Practice Address - Country:US
Practice Address - Phone:847-337-9051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA120791207PE0004X
MI4301094367390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program