Provider Demographics
NPI:1144686577
Name:PARK, TONY JUNGWOO
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:JUNGWOO
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 SCARLET BLOOM
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-8808
Mailing Address - Country:US
Mailing Address - Phone:858-740-4142
Mailing Address - Fax:
Practice Address - Street 1:7212 ORANGETHORPE AVE STE 9A
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-4668
Practice Address - Country:US
Practice Address - Phone:714-503-6550
Practice Address - Fax:714-409-3075
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA835101163W00000X
CA95003723363LF0000X
CA2020011541363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily