Healthcare Provider Details

I. General information

NPI: 1932441425
Provider Name (Legal Business Name): ESTHER SOUYON PARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 10/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11845 W OLYMPIC BLVD STE 900W
LOS ANGELES CA
90064-5086
US

IV. Provider business mailing address

690 VETERAN AVE APT 215
LOS ANGELES CA
90024-1935
US

V. Phone/Fax

Practice location:
  • Phone: 424-272-7502
  • Fax:
Mailing address:
  • Phone: 443-480-7255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number143191
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: