Basic Information
| Provider Information | |||||||||
| NPI: | 1215027008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18436 ROSCOE BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913254107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555044544 | ||||||||
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| Practice Location | |||||||||
| Address1: | DILOREZNO TRICARE HEALTH CLINIC | ||||||||
| Address2: | FEDERAL BUILDING 2, RM 1345 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 203700001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036142726 | ||||||||
| FaxNumber: | 7036141593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | C54964 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.