Healthcare Provider Details

I. General information

NPI: 1982946323
Provider Name (Legal Business Name): RICHARD PARK M.D., A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
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
91362-4943
US

V. Phone/Fax

Practice location:
  • Phone: 818-678-9875
  • Fax: 747-200-2589
Mailing address:
  • Phone: 805-368-1293
  • Fax: 888-981-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RICHARD PARK
Title or Position: CEO/PHYSICIAN
Credential: M.D.
Phone: 818-678-9875