Basic Information
| Provider Information | |||||||||
| NPI: | 1619147899 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GIL S PARK, MD, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 21ST ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933013144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613240300 | ||||||||
| FaxNumber: | 6613244095 | ||||||||
| Practice Location | |||||||||
| Address1: | 6000 PHYSICIANS BLVD | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933015840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613224744 | ||||||||
| FaxNumber: | 6613222938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2008 | ||||||||
| LastUpdateDate: | 03/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | PARK | ||||||||
| AuthorizedOfficialFirstName: | GIL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6613240300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | AA31383 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A313830 | 05 | CA | MEDICAID |