Healthcare Provider Details

I. General information

NPI: 1144970799
Provider Name (Legal Business Name): JAMES PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2022
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

400 N PEPPER AVE
COLTON CA
92324-1801
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-2178
  • Fax:
Mailing address:
  • Phone: 909-580-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA188301
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: