Provider Demographics
NPI:1558524306
Name:JEONG SIK PARK MD A PROF CORP
Entity Type:Organization
Organization Name:JEONG SIK PARK MD A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-994-8818
Mailing Address - Street 1:PO BOX 6017
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-6017
Mailing Address - Country:US
Mailing Address - Phone:707-995-7077
Mailing Address - Fax:
Practice Address - Street 1:15250 LAKESHORE DR STE C
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8107
Practice Address - Country:US
Practice Address - Phone:707-995-7077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45408174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A454080Medicaid