Healthcare Provider Details

I. General information

NPI: 1801802335
Provider Name (Legal Business Name): GREGORY CHARLES PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3998 VISTA WAY SUITE A
OCEANSIDE CA
92056-4500
US

IV. Provider business mailing address

3998 VISTA WAY SUITE A
OCEANSIDE CA
92056-4500
US

V. Phone/Fax

Practice location:
  • Phone: 760-655-1414
  • Fax: 760-655-1415
Mailing address:
  • Phone: 760-655-1414
  • Fax: 760-655-1415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG89460
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: