Provider Demographics
NPI:1750632501
Name:PARK, JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 S DIAMOND BAR BLVD UNIT 4233
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-5610
Mailing Address - Country:US
Mailing Address - Phone:909-274-9119
Mailing Address - Fax:
Practice Address - Street 1:1370 VALLEY VISTA DR STE 200
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765
Practice Address - Country:US
Practice Address - Phone:909-274-9119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30065103T00000X
CA390200000X
CAPSY30065103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty