Provider Demographics
NPI:1851478358
Name:BRUCE PARK, M.D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BRUCE PARK, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:BRUCE PARK MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-525-0545
Mailing Address - Street 1:1966 E CHAPMAN AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-4142
Mailing Address - Country:US
Mailing Address - Phone:714-562-0542
Mailing Address - Fax:
Practice Address - Street 1:1966 E CHAPMAN AVE
Practice Address - Street 2:SUITE G
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-4142
Practice Address - Country:US
Practice Address - Phone:714-525-0545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ05140ZMedicare PIN
W20541Medicare PIN
W20541AMedicare PIN