Healthcare Provider Details

I. General information

NPI: 1508918616
Provider Name (Legal Business Name): BRIAN DUKE PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 CAPITOL AVE DEPT 402
SACRAMENTO CA
95816-6032
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD STE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 916-262-9400
  • Fax: 916-262-9399
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME 115350
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA97247
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: