MEDICARE: DR. EDWARD HYUNJOON PARK M.D.

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	174400000X	Specialist	A75993	CA

General Provider Information

NPI Number	:	1447344429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD HYUNJOON PARK M.D.

Provider Business Mailing Address
First Line	:	1330 SAN BERNARDINO RD
Second Line	:	SUITE C
City	:	UPLAND
State	:	CA
Zip	:	91786-4928
Country	:	US
Telephone Number	:	909-981-8985
Fax Number	:	909-949-4550

Provider Business Practice Location Address
First Line	:	1330 SAN BERNARDINO RD
Second Line	:	SUITE C
City	:	UPLAND
State	:	CA
Zip	:	91786-4928
Country	:	US
Telephone Number	:	909-981-8985
Fax Number	:	909-949-4550

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	08/12/2010

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