Provider Demographics
NPI:1215975594
Name:PARK, PATRICK T (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:T
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 1:266 S HARVARD BLVD
Mailing Address - Street 2:320
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-4372
Mailing Address - Country:US
Mailing Address - Phone:213-739-1025
Mailing Address - Fax:213-739-9936
Practice Address - Street 1:266 S HARVARD BLVD
Practice Address - Street 2:320
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-4372
Practice Address - Country:US
Practice Address - Phone:213-739-1025
Practice Address - Fax:213-739-9936
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76980174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G769800Medicaid
CA00G769800Medicaid
CAG76980Medicare ID - Type Unspecified