Basic Information
| Provider Information | |||||||||
| NPI: | 1780974212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | SHAUN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54701 FILE NUMBER | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11175 CAMPUS ST | ||||||||
| Address2: | CP-A1121 | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923501700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095588142 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2011 | ||||||||
| LastUpdateDate: | 07/02/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A122388 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.