Provider Demographics
NPI:1992929616
Name:PARK, MI RAN (MD)
Entity type:Individual
Prefix:DR
First Name:MI RAN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MI RAN
Other - Middle Name:
Other - Last Name:CHUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5150 GRAVES AVE.
Mailing Address - Street 2:SUITE 11B
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-5014
Mailing Address - Country:US
Mailing Address - Phone:408-293-0800
Mailing Address - Fax:408-293-0801
Practice Address - Street 1:5150 GRAVES AVE.
Practice Address - Street 2:SUITE 11B
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-5014
Practice Address - Country:US
Practice Address - Phone:408-293-0800
Practice Address - Fax:408-293-0801
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103558207Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABZ816AMedicare PIN