Provider Demographics
NPI:1255651378
Name:LOUIS S PARK M D INC
Entity type:Organization
Organization Name:LOUIS S PARK M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:SANGSOO
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-613-4945
Mailing Address - Street 1:1300 N VERMONT AVE # 600
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6098
Mailing Address - Country:US
Mailing Address - Phone:213-484-8446
Mailing Address - Fax:323-913-4351
Practice Address - Street 1:1300 N VERMONT AVE # 600
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6098
Practice Address - Country:US
Practice Address - Phone:213-484-8446
Practice Address - Fax:323-913-4351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-11
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79245207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G792450Medicaid
CA00G792450Medicaid