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General NPI Number Information
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NPI Number | 1932289030
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Entity Type | Individual
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Provider Name | MICHAEL KWANSUP PARK MD
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Gender | Male
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Dates
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Enumeration Date | 10/16/2006
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Last Update Date | 08/27/2019
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Provider Practice Location Address
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Address Line | 1940 WEBSTER ST 2ND FLOOR
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City | OAKLAND
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State | CA
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Zip | 94612-2920
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Country | US
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Telephone | 510-463-4700
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Fax | 510-463-4722
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Provider Business Mailing Address
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Address Line | 5700 TELEGRAPH AVE STE 100
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City | OAKLAND
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State | CA
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Zip | 94609-1710
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Country | US
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Telephone | 510-463-4700
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | G75378
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License Number State | CA
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