Provider Demographics
NPI:1184914046
Name:PARK, BEAU YUN (MD)
Entity type:Individual
Prefix:
First Name:BEAU
Middle Name:YUN
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 1:531 D ST APT C
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-4068
Mailing Address - Country:US
Mailing Address - Phone:310-736-0394
Mailing Address - Fax:
Practice Address - Street 1:100A DRAKES LANDING RD
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2438
Practice Address - Country:US
Practice Address - Phone:415-461-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC185568207VG0400X
PAMD461241207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033491940001Medicaid