MEDICARE: MR. JAMES JONGTAK PARK D.O.

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	2084N0400X	Neurology Physician	20A7365	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00AX73650	OTHER	CA	MEDI-CAL
2	ZZZ04904Z	OTHER	CA	BLUE SHIELD OF CALIFORNIA

General Provider Information

NPI Number	:	1306871421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES JONGTAK PARK D.O.

Provider Business Mailing Address
First Line	:	11 FLORA SPGS
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92602-2412
Country	:	US
Telephone Number	:	714-847-7392
Fax Number	:	714-847-7396

Provider Business Practice Location Address
First Line	:	17822 BEACH BLVD
Second Line	:	SUITE 419
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-7101
Country	:	US
Telephone Number	:	714-841-9922
Fax Number	:	714-841-3292

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	07/26/2007

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