MEDICARE: DR. JOSEPH PARK DPM

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	213ES0103X	Foot & Ankle Surgery Podiatrist	E4797	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1982886412	OTHER	CA	PODIATRY

General Provider Information

NPI Number	:	1982886412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH PARK DPM

Provider Business Mailing Address
First Line	:	191 S BUENA VISTA ST STE 315
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4556
Country	:	US
Telephone Number	:	818-848-5586
Fax Number	:

Provider Business Practice Location Address
First Line	:	191 S BUENA VISTA ST STE 315
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4556
Country	:	US
Telephone Number	:	818-848-5586
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2007
Last Update Date	:	02/23/2009

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