Provider Demographics
NPI:1831175918
Name:PARK, TAIKEUN (MD)
Entity type:Individual
Prefix:
First Name:TAIKEUN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KEN
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:13788 TORREY DEL MAR DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-5629
Mailing Address - Country:US
Mailing Address - Phone:858-997-5927
Mailing Address - Fax:
Practice Address - Street 1:251 LANDIS AVENUE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-9578
Practice Address - Country:US
Practice Address - Phone:619-515-2500
Practice Address - Fax:619-934-9578
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51444208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
E14984Medicare UPIN