Provider Demographics
NPI:1841378825
Name:PARK, BRUCE S (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:S
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 1:1966 E CHAPMAN AVE STE G
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-4141
Mailing Address - Country:US
Mailing Address - Phone:714-525-0545
Mailing Address - Fax:714-441-1821
Practice Address - Street 1:1966 E CHAPMAN AVE STE G
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-4141
Practice Address - Country:US
Practice Address - Phone:714-525-0545
Practice Address - Fax:714-441-1821
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64842207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H38786Medicare UPIN
00A648421Medicare PIN
CAA64842Medicare ID - Type Unspecified
WA64842BMedicare PIN
WA64842CMedicare PIN