Provider Demographics
NPI:1962497149
Name:PARK, KERRY (MD)
Entity type:Individual
Prefix:
First Name:KERRY
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 1:2801 S SAN PEDRO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-2023
Mailing Address - Country:US
Mailing Address - Phone:323-233-3100
Mailing Address - Fax:323-233-4100
Practice Address - Street 1:1005 E WASHINGTON BLVD
Practice Address - Street 2:SUITE A-1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90021-3020
Practice Address - Country:US
Practice Address - Phone:323-233-3100
Practice Address - Fax:323-233-4100
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77252174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA522355131OtherTAX ID #
CA00G772520Medicaid
CAG39493OtherPTAN
CAG39493Medicare UPIN
CAG77252Medicare PIN