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General NPI Number Information
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NPI Number | 1932272846
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Entity Type | Organization
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Legal Business Name | BRUCE PARK, MD
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Dates
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Enumeration Date | 11/16/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7872 WALKER ST SUITE 108
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City | LA PALMA
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State | CA
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Zip | 90623-1796
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Country | US
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Telephone | 714-562-0542
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3430
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City | CERRITOS
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State | CA
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Zip | 90703-3430
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Country | US
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Telephone | 714-562-0542
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRUCE S PARK
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Credential | MD
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Telephone | 714-562-0542
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | A64842
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License Number State | CA
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