Healthcare Provider Details

I. General information

NPI: 1720215486
Provider Name (Legal Business Name): JONATHAN KEON PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 LOMITA BLVD
TORRANCE CA
90505-5002
US

IV. Provider business mailing address

3330 LOMITA BLVD
TORRANCE CA
90505-5002
US

V. Phone/Fax

Practice location:
  • Phone: 310-325-9110
  • Fax:
Mailing address:
  • Phone: 310-325-9111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA113114
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: