Provider Demographics
NPI:1982946323
Name:RICHARD PARK M.D., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:RICHARD PARK M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-678-9875
Mailing Address - Street 1:2709 ROCKY POINT CT
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-4943
Mailing Address - Country:US
Mailing Address - Phone:805-368-1293
Mailing Address - Fax:888-981-8739
Practice Address - Street 1:10515 BALBOA BLVD STE 325
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6364
Practice Address - Country:US
Practice Address - Phone:818-678-9875
Practice Address - Fax:747-200-2589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-25
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone