Provider Demographics
NPI:1124821194
Name:PARK, SA HEEN (MD)
Entity type:Individual
Prefix:
First Name:SA HEEN
Middle Name:
Last Name:PARK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1403 LOMITA BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-2084
Mailing Address - Country:US
Mailing Address - Phone:310-602-2550
Mailing Address - Fax:
Practice Address - Street 1:1403 LOMITA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-2084
Practice Address - Country:US
Practice Address - Phone:310-602-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty