Healthcare Provider Details

I. General information

NPI: 1205833811
Provider Name (Legal Business Name): PETER H PAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD STE 280W
SANTA MONICA CA
90404-2172
US

IV. Provider business mailing address

2001 SANTA MONICA BLVD SUITE 280W
SANTA MONICA CA
90404-2102
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-7678
  • Fax: 310-829-6889
Mailing address:
  • Phone: 310-829-7678
  • Fax: 310-829-6889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG84741
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License NumberG84741
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: