Provider Demographics
NPI:1245823541
Name:PARK, ROY (JD)
Entity type:Individual
Prefix:MR
First Name:ROY
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 FRESNO ST STE 100
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1718
Mailing Address - Country:US
Mailing Address - Phone:559-600-3546
Mailing Address - Fax:
Practice Address - Street 1:2135 FRESNO ST STE 100
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1718
Practice Address - Country:US
Practice Address - Phone:559-600-3546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator