Provider Demographics
NPI:1871113050
Name:PARK, TED (MD)
Entity type:Individual
Prefix:
First Name:TED
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 1:12291 WASHINGTON BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90606-2551
Mailing Address - Country:US
Mailing Address - Phone:562-698-2541
Mailing Address - Fax:562-789-4340
Practice Address - Street 1:12291 WASHINGTON BLVD STE 500
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-2551
Practice Address - Country:US
Practice Address - Phone:562-698-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2025-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA178286207Q00000X
WAMD61411462207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine