Provider Demographics
NPI:1710181854
Name:PARK, SAMUEL WAN (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WAN
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 1:26730 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6364
Mailing Address - Country:US
Mailing Address - Phone:949-364-2154
Mailing Address - Fax:949-496-8872
Practice Address - Street 1:26730 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-364-2154
Practice Address - Fax:949-496-8872
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96320207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery