Healthcare Provider Details

I. General information

NPI: 1518661867
Provider Name (Legal Business Name): JOHN PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5105 W 1ST ST # 101
SANTA ANA CA
92703-3069
US

IV. Provider business mailing address

6923 MAGNOLIA AVE
BUENA PARK CA
90621-1177
US

V. Phone/Fax

Practice location:
  • Phone: 213-574-2248
  • Fax:
Mailing address:
  • Phone: 213-574-2248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA196669
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: