Basic Information
| Provider Information | |||||||||
| NPI: | 1578738522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 GILMAN DRIVE | ||||||||
| Address2: | MC 0304 | ||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920930304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585343755 | ||||||||
| FaxNumber: | 8585342628 | ||||||||
| Practice Location | |||||||||
| Address1: | 9500 GILMAN DRIVE | ||||||||
| Address2: | MC 0304 | ||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920930304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585343755 | ||||||||
| FaxNumber: | 8585342628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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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 | 103T00000X | PSY16648 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | 103TC1900X | PSY16648 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.