Provider Demographics
NPI:1740368984
Name:PARK, EDWARD HENRY (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:HENRY
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3980 WILSHIRE BLVD APT 735
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-4224
Mailing Address - Country:US
Mailing Address - Phone:714-369-8633
Mailing Address - Fax:213-214-3935
Practice Address - Street 1:3980 WILSHIRE BLVD APT 735
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-4224
Practice Address - Country:US
Practice Address - Phone:714-369-8633
Practice Address - Fax:213-214-3935
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME151720207Q00000X
TXT4994207Q00000X
CAG83999207Q00000X
HIMD20796207Q00000X
NY310574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG71672Medicare UPIN