Healthcare Provider Details

I. General information

NPI: 1811036619
Provider Name (Legal Business Name): JINHA MARK PARK M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 09/30/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W CALIFORNIA BLVD
PASADENA CA
91105-3010
US

IV. Provider business mailing address

223 N 1ST AVE
ARCADIA CA
91006-7027
US

V. Phone/Fax

Practice location:
  • Phone: 626-397-5139
  • Fax:
Mailing address:
  • Phone: 626-821-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA80100
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberA80100
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: