Provider Demographics
NPI:1265410476
Name:PARK, BRIAN CHOI (DPM)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHOI
Last Name:PARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 LOMITA BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4930
Mailing Address - Country:US
Mailing Address - Phone:310-328-8660
Mailing Address - Fax:310-294-9994
Practice Address - Street 1:3400 LOMITA BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4930
Practice Address - Country:US
Practice Address - Phone:310-328-8660
Practice Address - Fax:310-294-9994
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4121213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E41213Medicaid
CA000E41213Medicaid
U70524Medicare UPIN
CA5090120001Medicare NSC