Healthcare Provider Details

I. General information

NPI: 1174718134
Provider Name (Legal Business Name): RICHARD PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10515 BALBOA BLVD STE 325
GRANADA HILLS CA
91344-6364
US

IV. Provider business mailing address

2709 ROCKY POINT CT.
THOUSAND OAKS CA
91362
US

V. Phone/Fax

Practice location:
  • Phone: 186-789-8758
  • Fax: 747-200-2589
Mailing address:
  • Phone: 661-319-1908
  • Fax: 888-981-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA111560
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA111560
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA111560
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: