Provider Demographics
NPI:1881030666
Name:JUN KYU PARK, M.D. INC.
Entity Type:Organization
Organization Name:JUN KYU PARK, M.D. INC.
Other - Org Name:JUN PARK MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUN
Authorized Official - Middle Name:KYU
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-984-1942
Mailing Address - Street 1:6236 MAMMOTH AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-2936
Mailing Address - Country:US
Mailing Address - Phone:818-984-1942
Mailing Address - Fax:818-786-5417
Practice Address - Street 1:7300 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1902
Practice Address - Country:US
Practice Address - Phone:818-984-1942
Practice Address - Fax:818-786-5417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98074207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0392239Medicaid
CACD104AOtherMEDICARE PROVIDER NUMBER