Healthcare Provider Details

I. General information

NPI: 1801425715
Provider Name (Legal Business Name): SOPHIA ANNE PARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SEONYEONG PARK MD

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 10/27/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

4650 W SUNSET BLVD # MS 76
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 888-499-9303
  • Fax:
Mailing address:
  • Phone: 888-499-9303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA186190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: