Provider Demographics
NPI:1740285907
Name:PARK, SAMUEL MO (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:MO
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 1:236 W EAST AVE STE A
Mailing Address - Street 2:PMB 253
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-7236
Mailing Address - Country:US
Mailing Address - Phone:530-342-2777
Mailing Address - Fax:530-342-2776
Practice Address - Street 1:340 W EAST AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-7238
Practice Address - Country:US
Practice Address - Phone:530-342-2777
Practice Address - Fax:530-342-2776
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076716P208100000X
CAG87601208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3697637Medicaid
CA3697637Medicaid
OHPA0880051Medicare ID - Type Unspecified
OHG36514Medicare UPIN