Healthcare Provider Details

I. General information

NPI: 1124333455
Provider Name (Legal Business Name): LILY PARK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 COFFEE RD
MODESTO CA
95355-4201
US

IV. Provider business mailing address

3105 CEDAR RAVINE RD STE 201
PLACERVILLE CA
95667-6561
US

V. Phone/Fax

Practice location:
  • Phone: 209-521-6097
  • Fax:
Mailing address:
  • Phone: 530-626-1602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A12765
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101018747
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO184048
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number20A12765
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number12765
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: