Healthcare Provider Details

I. General information

NPI: 1912035973
Provider Name (Legal Business Name): THOMAS C. PARK, M.D., CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UNIVERSITY AVE SUITE 260
SACRAMENTO CA
95825-6504
US

IV. Provider business mailing address

PO BOX 4357
DAVIS CA
95617-4357
US

V. Phone/Fax

Practice location:
  • Phone: 916-929-6705
  • Fax: 916-929-6641
Mailing address:
  • Phone: 916-929-6705
  • Fax: 916-929-6641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberG681040
License Number StateCA

VIII. Authorized Official

Name: THOMAS C PARK
Title or Position: OWNER
Credential: MD
Phone: 916-929-6705