Provider Demographics
NPI:1336116201
Name:PARK, SUNG JAE (MD)
Entity Type:Individual
Prefix:
First Name:SUNG
Middle Name:JAE
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 1:2235 DUBOIS DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3212
Mailing Address - Country:US
Mailing Address - Phone:574-267-8189
Mailing Address - Fax:574-267-7554
Practice Address - Street 1:2235 DUBOIS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3212
Practice Address - Country:US
Practice Address - Phone:574-267-8189
Practice Address - Fax:574-267-7554
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051341207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200248760AMedicaid
INH06975Medicare UPIN
IN262490RRMedicare PIN
IN200248760AMedicaid