Healthcare Provider Details

I. General information

NPI: 1164582656
Provider Name (Legal Business Name): SANGDO PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 BEVERLY BLVD SUITE 223
LOS ANGELES CA
90057-2216
US

IV. Provider business mailing address

2105 BEVERLY BLVD SUITE 223
LOS ANGELES CA
90057-2216
US

V. Phone/Fax

Practice location:
  • Phone: 213-989-0644
  • Fax:
Mailing address:
  • Phone: 213-989-0644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberN6562
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA107642
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: