Provider Demographics
NPI:1962495572
Name:PARK, MIN SEUK (MD)
Entity Type:Individual
Prefix:DR
First Name:MIN
Middle Name:SEUK
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4735 GOULD AVE
Mailing Address - Street 2:
Mailing Address - City:LA CANADA FLINTRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91011-2629
Mailing Address - Country:US
Mailing Address - Phone:323-377-9143
Mailing Address - Fax:
Practice Address - Street 1:2681 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2810
Practice Address - Country:US
Practice Address - Phone:213-382-0031
Practice Address - Fax:213-480-0463
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG78220207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG78220OtherSTATE LICENSE NUMBER
CA00G782200Medicaid
CAG34928Medicare UPIN
CAWG78220EMedicare ID - Type Unspecified