Provider Demographics
NPI:1932289030
Name:PARK, MICHAEL KWANSUP (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KWANSUP
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 1:5700 TELEGRAPH AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1710
Mailing Address - Country:US
Mailing Address - Phone:510-463-4700
Mailing Address - Fax:
Practice Address - Street 1:1940 WEBSTER ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2920
Practice Address - Country:US
Practice Address - Phone:510-463-4700
Practice Address - Fax:510-463-4722
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75378208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE91026OtherMEDICARE
CA00G753781Medicare PIN
G01899Medicare UPIN