Provider Demographics
NPI:1730324443
Name:EDWARD H. PARK MD., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:EDWARD H. PARK MD., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:
Authorized Official - Last Name:SZARZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-981-8985
Mailing Address - Street 1:1330 SAN BERNARDINO RD STE C
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4980
Mailing Address - Country:US
Mailing Address - Phone:909-981-8985
Mailing Address - Fax:
Practice Address - Street 1:1330 SAN BERNARDINO RD STE C
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4980
Practice Address - Country:US
Practice Address - Phone:909-981-8985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75993174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI50185Medicare UPIN