MEDICARE: DR. MI RAN 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	207Q00000X	Family Medicine Physician	A103558	CA
2	261QP2300X	Primary Care Clinic/Center	A103558	CA

General Provider Information

NPI Number	:	1992929616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MI RAN PARK M.D.

Provider Business Mailing Address
First Line	:	5150 GRAVES AVE.
Second Line	:	SUITE 11B
City	:	SAN JOSE
State	:	CA
Zip	:	95129-5014
Country	:	US
Telephone Number	:	408-293-0800
Fax Number	:	408-293-0801

Provider Business Practice Location Address
First Line	:	5150 GRAVES AVE.
Second Line	:	SUITE 11B
City	:	SAN JOSE
State	:	CA
Zip	:	95129-5014
Country	:	US
Telephone Number	:	408-293-0800
Fax Number	:	408-293-0801

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	11/21/2013

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