Provider Demographics
NPI:1043409048
Name:PARK, JEANIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANIE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 CLAIRMONT RD
Mailing Address - Street 2:RENAL/NEPHROLOGY AND HEMODIALYSIS MED (111)
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4004
Mailing Address - Country:US
Mailing Address - Phone:404-321-6111
Mailing Address - Fax:404-235-3049
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:MOT 8TH FLOOR
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2208
Practice Address - Country:US
Practice Address - Phone:404-686-5038
Practice Address - Fax:404-686-4995
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061137207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology