Provider Demographics
NPI:1841602315
Name:PARK, TIMOTHY D (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:PARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 BEARD RD
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-3442
Mailing Address - Country:US
Mailing Address - Phone:818-281-9289
Mailing Address - Fax:707-252-9325
Practice Address - Street 1:801 SENECA ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-1411
Practice Address - Country:US
Practice Address - Phone:818-281-9289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-04896207Q00000X, 2084P0800X
CA20A159602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine