Healthcare Provider Details

I. General information

NPI: 1285669085
Provider Name (Legal Business Name): TARI Y PARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: YOUNG JU PARK

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E CHASE AVE 108
EL CAJON CA
92020-6305
US

IV. Provider business mailing address

3860 CALLE FORTUNADA 200
SAN DIEGO CA
92123-4800
US

V. Phone/Fax

Practice location:
  • Phone: 619-442-2560
  • Fax: 619-442-7836
Mailing address:
  • Phone: 858-636-4300
  • Fax: 858-636-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA74537
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: