Provider Demographics
NPI:1124006523
Name:PARK, JUNG I (MD)
Entity Type:Individual
Prefix:DR
First Name:JUNG
Middle Name:I
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8825 CRESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2711
Mailing Address - Country:US
Mailing Address - Phone:219-746-9600
Mailing Address - Fax:
Practice Address - Street 1:8825 CRESTWOOD AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2711
Practice Address - Country:US
Practice Address - Phone:219-746-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032400A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN234393Medicaid
IN234393Medicaid
IN629520Medicare ID - Type Unspecified