Provider Demographics
NPI:1124698733
Name:PARK, DANIEL DONGSU
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:DONGSU
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DONG SU
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6 COMANCHE CIR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4702
Mailing Address - Country:US
Mailing Address - Phone:909-573-5956
Mailing Address - Fax:
Practice Address - Street 1:6 COMANCHE CIR
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-4702
Practice Address - Country:US
Practice Address - Phone:909-573-5956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-26
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA561016163WC1500X
CA95223747163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health