Healthcare Provider Details

I. General information

NPI: 1083293112
Provider Name (Legal Business Name): MOON JOON PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6733 N WILLOW AVE STE 107
FRESNO CA
93710-5953
US

IV. Provider business mailing address

1313 E HERNDON AVE
FRESNO CA
93720-3306
US

V. Phone/Fax

Practice location:
  • Phone: 559-435-4700
  • Fax: 559-298-7951
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA192818
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberA192818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: