Provider Demographics
NPI:1306871421
Name:PARK, JAMES JONGTAK (DO)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:JONGTAK
Last Name:PARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 FLORA SPGS
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-2412
Mailing Address - Country:US
Mailing Address - Phone:714-847-7392
Mailing Address - Fax:714-847-7396
Practice Address - Street 1:17822 BEACH BLVD
Practice Address - Street 2:SUITE 419
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-7101
Practice Address - Country:US
Practice Address - Phone:714-841-9922
Practice Address - Fax:714-841-3292
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A73652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX73650OtherMEDI-CAL
CAZZZ04904ZOtherBLUE SHIELD OF CALIFORNIA
CAZZZ04904ZOtherBLUE SHIELD OF CALIFORNIA
CAW20A7365BMedicare ID - Type UnspecifiedMCARE PPIN