Provider Demographics
NPI:1750578761
Name:SUNG-UN JUSTIN PARK M.D., INC.
Entity type:Organization
Organization Name:SUNG-UN JUSTIN PARK M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-484-8054
Mailing Address - Street 1:3055 W ORANGE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3152
Mailing Address - Country:US
Mailing Address - Phone:714-484-8054
Mailing Address - Fax:714-484-8072
Practice Address - Street 1:3055 W ORANGE AVE STE 101
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3152
Practice Address - Country:US
Practice Address - Phone:714-484-8054
Practice Address - Fax:714-484-8072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA487042084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A487041Medicaid
CAA48704OtherLICENSE NUMBER
CAA48704OtherLICENSE NUMBER
CAW17951Medicare PIN