=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497832661
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL K. PARK M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20072 SW BIRCH ST STE 100
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-0794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-757-1150
-----------------------------------------------------
Fax | 949-757-1170
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20072 SW BIRCH ST STE 100
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-0794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-757-1150
-----------------------------------------------------
Fax | 949-757-1170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A050474
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------