Healthcare Provider Details

I. General information

NPI: 1053375444
Provider Name (Legal Business Name): JOHN W PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 DIVISADERO ST 2ND FLOOR, BOX 1710
SAN FRANCISCO CA
94115-3010
US

IV. Provider business mailing address

1635 DIVISADERO ST STE. 625, BOX 1821
SAN FRANCISCO CA
94143-0001
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-7070
  • Fax: 415-353-7021
Mailing address:
  • Phone: 415-476-4029
  • Fax: 415-476-4150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberG63196
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: