Basic Information
| Provider Information | |||||||||
| NPI: | 1831175918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | TAIKEUN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | PARK | ||||||||
| OtherFirstName: | KEN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13788 TORREY DEL MAR DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921305629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589975927 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 251 LANDIS AVENUE | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919109578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152500 | ||||||||
| FaxNumber: | 6199349578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | C51444 | CA | N | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | C51444 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.