Provider Demographics
NPI:1396015152
Name:PARK, JOHNNY (HAD)
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 S VERMONT AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2721
Mailing Address - Country:US
Mailing Address - Phone:213-368-6300
Mailing Address - Fax:
Practice Address - Street 1:1058 S VERMONT AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2721
Practice Address - Country:US
Practice Address - Phone:213-368-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7708237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7708OtherHEARING AID DISPENSER