MEDICARE: ESTHER PARK, D.O., LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	20A7734	CA

General Provider Information

NPI Number	:	1104002096
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESTHER PARK, D.O., LLC

Provider Business Mailing Address
First Line	:	1101 DOVE ST
Second Line	:	SUITE 130
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-2844
Country	:	US
Telephone Number	:	949-258-3741
Fax Number	:	949-258-3742

Provider Business Practice Location Address
First Line	:	1101 DOVE ST
Second Line	:	SUITE 130
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-2844
Country	:	US
Telephone Number	:	949-258-3741
Fax Number	:	949-258-3742

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. PAUL KIM
Credential	:
Telephone Number	:	949-258-3741

Provider Enumeration Date	:	01/10/2008
Last Update Date	:	01/03/2012

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