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General NPI Number Information
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NPI Number | 1740677111
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Entity Type | Organization
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Legal Business Name | MICHELLE JO PARK, MD, INC.
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Dates
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Enumeration Date | 04/23/2015
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Last Update Date | 04/23/2015
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Provider Practice Location Address
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Address Line | 4199 CAMPUS DR SUITE 550
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City | IRVINE
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State | CA
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Zip | 92612-4684
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Country | US
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Telephone | 949-864-6784
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Fax |
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Provider Business Mailing Address
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Address Line | 4199 CAMPUS DR SUITE 550
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City | IRVINE
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State | CA
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Zip | 92612-4684
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MICHELLE PARK
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Credential | M.D.
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Telephone | 949-864-6784
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | A106354
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License Number State | CA
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