Provider Demographics
NPI:1982678447
Name:PARK, EDWARD H
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:H
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10080 N WOLFE RD
Mailing Address - Street 2:SW3-100
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-2515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10080 N WOLFE RD
Practice Address - Street 2:SW3-100
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-2515
Practice Address - Country:US
Practice Address - Phone:408-342-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT29049OtherPHYSICAL THERAPIST LICENC