1801112891 NPI number — DR. BRANDON S PARK PHD

Table of content: DR. BRANDON S PARK PHD (NPI 1801112891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801112891 NPI number — DR. BRANDON S PARK PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
BRANDON
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801112891
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 9TH STREET
Provider Second Line Business Mailing Address:
ROOM 205 MAILSTOP 2-3
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95814-6414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-654-2431
Provider Business Mailing Address Fax Number:
916-654-3186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 NAPA VALLEJO HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94558-6234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-253-5000
Provider Business Practice Location Address Fax Number:
707-253-5513
Provider Enumeration Date:
04/15/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY24096 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)