Provider Demographics
NPI:1588794002
Name:PARK, JOSHUA (DC)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5257 STEVENS CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-6664
Mailing Address - Country:US
Mailing Address - Phone:408-260-9900
Mailing Address - Fax:
Practice Address - Street 1:5257 STEVENS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-6664
Practice Address - Country:US
Practice Address - Phone:408-260-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 26580111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0265800Medicare ID - Type Unspecified