Healthcare Provider Details

I. General information

NPI: 1114276854
Provider Name (Legal Business Name): JAMES PARK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 SUPERIOR AVE STE 205
NEWPORT BEACH CA
92663-3667
US

IV. Provider business mailing address

117 WINDSWEPT
IRVINE CA
92618-0853
US

V. Phone/Fax

Practice location:
  • Phone: 949-764-4006
  • Fax: 949-764-7398
Mailing address:
  • Phone: 267-258-7954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number20A16232
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number20A16232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: