Provider Demographics
NPI:1528078961
Name:PARK, JEONG SIK (MD)
Entity type:Individual
Prefix:
First Name:JEONG SIK
Middle Name:
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:PO BOX 6017
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-6017
Mailing Address - Country:US
Mailing Address - Phone:707-995-7077
Mailing Address - Fax:707-995-0904
Practice Address - Street 1:15250 LAKESHORE DR STE C
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8107
Practice Address - Country:US
Practice Address - Phone:707-995-7077
Practice Address - Fax:707-995-0904
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45408174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A454080Medicaid
CA00A454080Medicaid