Provider Demographics
NPI:1073691838
Name:PARK, DANIEL C (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:C
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 WEBSTER STREET
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607
Mailing Address - Country:US
Mailing Address - Phone:510-986-6800
Mailing Address - Fax:510-986-6896
Practice Address - Street 1:818 WEBSTER STREET
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607
Practice Address - Country:US
Practice Address - Phone:510-986-6800
Practice Address - Fax:510-986-6896
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51054207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G510540Medicaid
CA00G510540Medicaid
CA00G510540Medicaid