Basic Information
| Provider Information | |||||||||
| NPI: | 1174718134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2709 ROCKY POINT CT. | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613191908 | ||||||||
| FaxNumber: | 8889818739 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 W JANSS RD | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913601847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054972727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2007 | ||||||||
| LastUpdateDate: | 05/15/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A111560 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | A111560 | CA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208D00000X | A111560 | CA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1174718134 | 01 | NPI | OTHER |