Healthcare Provider Details

I. General information

NPI: 1205079910
Provider Name (Legal Business Name): RENEE E PARK M.D., M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2009
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

IV. Provider business mailing address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-5000
  • Fax:
Mailing address:
  • Phone: 877-608-0044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberMD454696
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberA135401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: