Provider Demographics
NPI:1942210570
Name:PARK, KYUNG I (MD)
Entity Type:Individual
Prefix:DR
First Name:KYUNG
Middle Name:I
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KYUNG
Other - Middle Name:IL
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:12362 BEACH BLVD
Mailing Address - Street 2:#10
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-3935
Mailing Address - Country:US
Mailing Address - Phone:714-248-9500
Mailing Address - Fax:714-622-4943
Practice Address - Street 1:12362 BEACH BLVD
Practice Address - Street 2:#10
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3935
Practice Address - Country:US
Practice Address - Phone:714-743-5733
Practice Address - Fax:714-622-4943
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2023-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC509802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC50980Medicare ID - Type Unspecified
CAC20184Medicare UPIN