Provider Demographics
NPI:1528205226
Name:KEVIN S PARK MD INC
Entity Type:Organization
Organization Name:KEVIN S PARK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:SONGCHOL
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-869-4421
Mailing Address - Street 1:11411 BROOKSHIRE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-4985
Mailing Address - Country:US
Mailing Address - Phone:562-869-4421
Mailing Address - Fax:562-869-3600
Practice Address - Street 1:11411 BROOKSHIRE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4985
Practice Address - Country:US
Practice Address - Phone:562-869-4421
Practice Address - Fax:562-869-3600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67776174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABM382AMedicare PIN
CAG98129Medicare UPIN