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General NPI Number Information
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NPI Number | 1558524306
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Entity Type | Organization
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Legal Business Name | JEONG SIK PARK MD A PROF CORP
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Dates
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Enumeration Date | 07/02/2008
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Last Update Date | 07/02/2008
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Provider Practice Location Address
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Address Line | 15250 LAKESHORE DR STE C
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City | CLEARLAKE
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State | CA
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Zip | 95422-8107
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Country | US
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Telephone | 707-995-7077
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6017
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City | CLEARLAKE
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State | CA
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Zip | 95422-6017
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Country | US
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Telephone | 707-995-7077
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Fax |
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Authorized Official
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Title or Position | MEDICAL BILLER
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Name | COLLEEN BRADRICK
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Credential |
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Telephone | 707-994-8818
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A45408
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License Number State | CA
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