Individual
KERRY PARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1005 E WASHINGTON BLVD, SUITE A-1, LOS ANGELES, CA 90021-3020
(323) 233-3100
(323) 233-4100
Mailing address
2801 S SAN PEDRO ST, LOS ANGELES, CA 90011-2023
(323) 233-3100
(323) 233-4100
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
G77252
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G772520
—
CA
01
—
522355131
TAX ID #
CA
01
—
G39493
PTAN
CA
Enumeration date
09/14/2005
Last updated
04/05/2019
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