Individual
LILY PARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
600 COFFEE RD, MODESTO, CA 95355-4201
(209) 521-6097
Mailing address
3105 CEDAR RAVINE RD, STE 201, PLACERVILLE, CA 95667-6561
(530) 626-1602
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
12765
CA
207R00000X
Internal Medicine Physician
20A12765
CA
207R00000X
Internal Medicine Physician
5101018747
MI
207R00000X
Internal Medicine Physician
DO184048
OR
208M00000X
Hospitalist Physician
20A12765
CA
Other
Enumeration date
08/11/2010
Last updated
08/08/2024
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