Provider Demographics
NPI:1912035973
Name:THOMAS C. PARK, M.D., CORPORATION
Entity Type:Organization
Organization Name:THOMAS C. PARK, M.D., CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-929-6705
Mailing Address - Street 1:PO BOX 4357
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617-4357
Mailing Address - Country:US
Mailing Address - Phone:916-929-6705
Mailing Address - Fax:916-929-6641
Practice Address - Street 1:500 UNIVERSITY AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6504
Practice Address - Country:US
Practice Address - Phone:916-929-6705
Practice Address - Fax:916-929-6641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG6810402086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF02280Medicare UPIN