Healthcare Provider Details

I. General information

NPI: 1720990203
Provider Name (Legal Business Name): SANGTAE PARK M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 N MEDICAL CENTER DR E STE 311
CLOVIS CA
93611-6892
US

IV. Provider business mailing address

260 SOUTH AVE
GLENCOE IL
60022-1754
US

V. Phone/Fax

Practice location:
  • Phone: 312-285-6267
  • Fax:
Mailing address:
  • Phone: 312-285-6267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SANGTAE PARK
Title or Position: PRESIDENT
Credential: MD
Phone: 312-285-6267