Provider Demographics
NPI:1588854962
Name:MIN S. PARK, M.D., INC.
Entity Type:Organization
Organization Name:MIN S. PARK, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-382-0031
Mailing Address - Street 1:4735 GOULD AVE
Mailing Address - Street 2:
Mailing Address - City:LA CANADA FLINTRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91011-2629
Mailing Address - Country:US
Mailing Address - Phone:213-382-0031
Mailing Address - Fax:213-480-0463
Practice Address - Street 1:2675 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2880
Practice Address - Country:US
Practice Address - Phone:213-382-0031
Practice Address - Fax:213-480-0463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78220207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18581OtherMEDICARE GROUP ID