Healthcare Provider Details

I. General information

NPI: 1285772731
Provider Name (Legal Business Name): JIN K PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3663 W 6TH ST #302
LOS ANGELES CA
90020-3049
US

IV. Provider business mailing address

3663 W 6TH ST #302
LOS ANGELES CA
90020-3049
US

V. Phone/Fax

Practice location:
  • Phone: 213-380-3306
  • Fax: 213-384-9753
Mailing address:
  • Phone: 213-380-3306
  • Fax: 213-384-9753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberA35787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: