Provider Demographics
NPI:1053464545
Name:PAK, JAYOUNG (MD)
Entity Type:Individual
Prefix:
First Name:JAYOUNG
Middle Name:
Last Name:PAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BERGEN ST
Mailing Address - Street 2:ADMC 12 1205
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 BERGEN ST
Practice Address - Street 2:SUITE 8100
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2425
Practice Address - Country:US
Practice Address - Phone:973-972-9000
Practice Address - Fax:973-972-2369
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05069000208000000X, 2084N0402X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5475708Medicaid
740924Medicare PIN
NJF54424Medicare UPIN