MEDICARE: MIN S. PARK, M.D., INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	G78220	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W18581	OTHER	CA	MEDICARE GROUP ID

General Provider Information

NPI Number	:	1588854962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIN S. PARK, M.D., INC.

Provider Business Mailing Address
First Line	:	4735 GOULD AVE
Second Line	:
City	:	LA CANADA FLINTRIDGE
State	:	CA
Zip	:	91011-2629
Country	:	US
Telephone Number	:	213-382-0031
Fax Number	:	213-480-0463

Provider Business Practice Location Address
First Line	:	2675 W OLYMPIC BLVD
Second Line	:	SUITE 100
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2880
Country	:	US
Telephone Number	:	213-382-0031
Fax Number	:	213-480-0463

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MIN S PARK
Credential	:	M.D.
Telephone Number	:	213-382-0031

Provider Enumeration Date	:	07/31/2007
Last Update Date	:	06/26/2012

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Directions to “MIN S. PARK, M.D., INC. ” Practice Location

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