Provider Demographics
NPI:1023107505
Name:PARK, HERAN ANGELA (MD)
Entity type:Individual
Prefix:
First Name:HERAN
Middle Name:ANGELA
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 E CHAPMAN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-3990
Mailing Address - Country:US
Mailing Address - Phone:714-500-0360
Mailing Address - Fax:714-532-3943
Practice Address - Street 1:4010 E CHAPMAN AVE STE C
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-3990
Practice Address - Country:US
Practice Address - Phone:714-500-0360
Practice Address - Fax:714-532-3943
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67916208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G679160Medicaid
CA00G679160Medicaid
WG67916DMedicare ID - Type Unspecified