1396013595 NPI number — GIL JA PARK

Table of content: GIL JA PARK (NPI 1396013595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396013595 NPI number — GIL JA PARK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
GIL
Provider Middle Name:
JA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1396013595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 HIGHFIELD GLN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92618-4042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-552-1178
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1330 E 17TH ST
Provider Second Line Business Practice Location Address:
T-0286
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-8500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-547-1042
Provider Business Practice Location Address Fax Number:
714-547-1042
Provider Enumeration Date:
12/02/2011

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: 183500000X , with the licence number:  45541 , 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