1154465631 NPI number — PETER PARK MD INC

Table of content: (NPI 1154465631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154465631 NPI number — PETER PARK MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETER PARK MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1154465631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 27206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90027-0206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-385-0675
Provider Business Mailing Address Fax Number:
213-365-6429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 W PICO BLVD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90006-3902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-388-2772
Provider Business Practice Location Address Fax Number:
213-388-2112
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ARAI
Authorized Official First Name:
PETER
Authorized Official Middle Name:
TAKAYUKI
Authorized Official Title or Position:
OWNER/MEDICAL DIRECTOR
Authorized Official Telephone Number:
213-388-2772

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A54976 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com