Provider Demographics
NPI:1750313557
Name:PAK, SANG JOON (DPM)
Entity Type:Individual
Prefix:DR
First Name:SANG
Middle Name:JOON
Last Name:PAK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:S
Other - Last Name:PAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:1023 SUNSET BLVD APT C
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-7257
Mailing Address - Country:US
Mailing Address - Phone:626-254-1538
Mailing Address - Fax:
Practice Address - Street 1:1711 W TEMPLE ST # 3600
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5421
Practice Address - Country:US
Practice Address - Phone:213-989-0700
Practice Address - Fax:213-989-0703
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4251213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4251OtherPODIATRY LICENSE NUMBER
CAE4251OtherPODIATRY LICENSE NUMBER
CAE4251Medicare PIN
CAWE4251AMedicare PIN