Healthcare Provider Details

I. General information

NPI: 1891997011
Provider Name (Legal Business Name): IRIS PARK KO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 NEILSON ST
WATSONVILLE CA
95076
US

IV. Provider business mailing address

4280 VIA ARBOLADA UNIT 228
LOS ANGELES CA
90042-5121
US

V. Phone/Fax

Practice location:
  • Phone: 831-724-4741
  • Fax: 831-763-6069
Mailing address:
  • Phone: 714-724-2756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2010004025
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01093177A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA110533
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number258895
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: