Provider Demographics
NPI:1922363183
Name:PARK, SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2448 HISTORIC DECATUR RD
Mailing Address - Street 2:STE 130
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-6127
Mailing Address - Country:US
Mailing Address - Phone:619-398-2960
Mailing Address - Fax:
Practice Address - Street 1:2448 HISTORIC DECATUR RD STE 130
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6127
Practice Address - Country:US
Practice Address - Phone:619-398-2960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1271252083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine