Provider Demographics
NPI:1629268750
Name:PARK, GRACE E (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:E
Last Name:PARK
Suffix:
Gender:F
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 62106
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93160-2106
Mailing Address - Country:US
Mailing Address - Phone:805-681-1760
Mailing Address - Fax:805-681-1768
Practice Address - Street 1:317 W PUEBLO ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-4310
Practice Address - Country:US
Practice Address - Phone:805-681-1760
Practice Address - Fax:805-681-1768
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC129985207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC129985OtherSTATE LICENSE