Healthcare Provider Details

I. General information

NPI: 1013045343
Provider Name (Legal Business Name): KEVIN WARREN PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 RIVER RD KINSHIP CENTER
SALINAS CA
93908-9601
US

IV. Provider business mailing address

124 RIVER RD KINSHIP CENTER
SALINAS CA
93908-9601
US

V. Phone/Fax

Practice location:
  • Phone: 831-455-4770
  • Fax: 831-455-4739
Mailing address:
  • Phone: 831-455-4770
  • Fax: 831-455-4739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberG65353
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: