Healthcare Provider Details

I. General information

NPI: 1174943377
Provider Name (Legal Business Name): SUNNY PARK MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2014
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 DOVER DR STE 126
NEWPORT BEACH CA
92660-5546
US

IV. Provider business mailing address

901 DOVER DR STE 126
NEWPORT BEACH CA
92660-5546
US

V. Phone/Fax

Practice location:
  • Phone: 949-873-5089
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberA114258
License Number StateCA

VIII. Authorized Official

Name: SUNNY PARK
Title or Position: CEO
Credential: MD
Phone: 267-456-5066