Provider Demographics
NPI:1215042072
Name:PARK, JESSE K (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:K
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 1:100 TOWER DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527
Mailing Address - Country:US
Mailing Address - Phone:630-325-8681
Mailing Address - Fax:630-325-3936
Practice Address - Street 1:100 TOWER DR
Practice Address - Street 2:SUITE 105
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527
Practice Address - Country:US
Practice Address - Phone:630-325-8681
Practice Address - Fax:630-325-3936
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036080235207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD36080235Medicaid
ILF57281Medicare UPIN
ILK24386Medicare ID - Type Unspecified
ILD36080235Medicaid