MEDICARE: SUNNY PARK MD, INC

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	207YS0123X	Facial Plastic Surgery Physician	A114258	CA

General Provider Information

NPI Number	:	1174943377
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNNY PARK MD, INC

Provider Business Mailing Address
First Line	:	901 DOVER DR STE 126
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-5546
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 DOVER DR STE 126
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-5546
Country	:	US
Telephone Number	:	949-873-5089
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	SUNNY PARK
Credential	:	MD
Telephone Number	:	267-456-5066

Provider Enumeration Date	:	04/26/2014
Last Update Date	:	01/09/2015

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