Provider Demographics
NPI:1225569817
Name:PARK, JUNG
Entity Type:Individual
Prefix:
First Name:JUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 WHITNEY AVE APT 34
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-3751
Mailing Address - Country:US
Mailing Address - Phone:213-446-7808
Mailing Address - Fax:
Practice Address - Street 1:255 WHITNEY AVE APT 34
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3751
Practice Address - Country:US
Practice Address - Phone:213-446-7808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program