Provider Demographics
NPI:1982886412
Name:PARK, JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 S BUENA VISTA ST STE 315
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4556
Mailing Address - Country:US
Mailing Address - Phone:818-848-5586
Mailing Address - Fax:
Practice Address - Street 1:191 S BUENA VISTA ST STE 315
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4556
Practice Address - Country:US
Practice Address - Phone:818-848-5586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4797213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1982886412OtherPODIATRY