Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | G155980 | CA |
NPI | 1003855313 |
---|---|
Provider Name | Dr. David Rae Park |
First Address | Cypress, CA 90630-4733 |
Second Address | Huntington Beach, CA 92647 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/06/2006 |
Last Update Date | 16/08/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
270681400 | (05) | FL |
48609 | BCBS (01) | FL |
G46118 | (02) | |
P00223219 | RAILROAD MEDICARE (01) |