Provider Demographics
NPI:1629031455
Name:PARK, WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
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:PO BOX 720300
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73172-0300
Mailing Address - Country:US
Mailing Address - Phone:800-749-4560
Mailing Address - Fax:405-751-3183
Practice Address - Street 1:ONE HOAG DR
Practice Address - Street 2:ECU DEPT
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4162
Practice Address - Country:US
Practice Address - Phone:949-764-5689
Practice Address - Fax:405-751-3183
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72990207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G729900670Medicaid
CAP00249783OtherRR MEDICARE
CA00G729900Medicaid
OK00G729900OtherBLUE SHIELD
CAF51381Medicare UPIN
CAWG72990GMedicare PIN