1932289030 NPI number — DR. MICHAEL KWANSUP PARK MD

Table of content: DR. MICHAEL KWANSUP PARK MD (NPI 1932289030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932289030 NPI number — DR. MICHAEL KWANSUP PARK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
MICHAEL
Provider Middle Name:
KWANSUP
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1932289030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 TELEGRAPH AVE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94609-1710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-463-4700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1940 WEBSTER ST
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94612-2920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-463-4700
Provider Business Practice Location Address Fax Number:
510-463-4722
Provider Enumeration Date:
10/16/2006

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: 208100000X , with the licence number:  G75378 , 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)

  • Identifier: E91026 . This is a "MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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