Robert Phil Park, PSY.D.

Primary specialty

PsychologistTaxonomy code 103T00000X

License

PSY20153 Issued in CA

Practice address

1305 Tommydon St
Stockton, CA 95210-3364

Phone

(209) 476-5211

NPI assigned

Dec 13, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Permanente Medical Group Inc

  • Internal Medicine Physician
  • Santa Clara, CA
  • NPI 1073606299
  Medicare reassignment NPD
• Permanente Medical Group Inc

  • Internal Medicine Physician
  • Redwood City, CA
  • NPI 1639252604
  NPD
• Permanente Medical Group, Inc

  • Clinical Medical Laboratory
  • San Jose, CA
  • NPI 1497971584
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165968000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1641168000000",
    "number": "1053472605",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1305 TOMMYDON ST",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952103364",
            "telephone_number": "209-476-5211"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1305 TOMMYDON ST",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952103364",
            "telephone_number": "209-476-5211"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PARK",
        "first_name": "ROBERT",
        "middle_name": "PHIL",
        "name_prefix": "Dr.",
        "credential": "PSY.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-12-13",
        "last_updated": "2022-01-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "CA",
            "license": "PSY20153",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/ncalceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "The Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "3454 Hillcrest Ave",
            "city": "Antioch",
            "state": "CA",
            "country_code": "US",
            "postal_code": "945318238",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Alice Park, MD
• Ann Park
• Jessika Denise Park, AMFT, LPCC
• Kyung Soo Park
• Maggie Park
• Adam Russell Parker, MD
• Amanda Parker
• Amanda Parker
• Christopher D Parker, D.D.S.
• Danikajo Nicole Parker

• Psychologist in Stockton, CA
• Providers in Stockton, CA by specialty
• Psychologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 3, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.