Provider Demographics
NPI:1336192301
Name:PARK, ROYAL SON (MD)
Entity Type:Individual
Prefix:
First Name:ROYAL
Middle Name:SON
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2927 LOMITA BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5118
Mailing Address - Country:US
Mailing Address - Phone:424-220-6388
Mailing Address - Fax:424-285-8289
Practice Address - Street 1:23600 TELO AVE STE 220
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4039
Practice Address - Country:US
Practice Address - Phone:310-602-5005
Practice Address - Fax:310-373-7895
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79808208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A798080Medicaid
CA00A798080Medicaid