Provider Demographics
NPI:1346297660
Name:PARK, TAE J (MD)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:J
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 1:500 FORT WORTH DR STE 140
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-7527
Mailing Address - Country:US
Mailing Address - Phone:940-320-0505
Mailing Address - Fax:940-320-0506
Practice Address - Street 1:500 FORT WORTH DR STE 140
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-7527
Practice Address - Country:US
Practice Address - Phone:940-320-0505
Practice Address - Fax:940-320-0506
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90047207R00000X
TXS1480207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A900470Medicaid
CA00A900470Medicaid
CAWA90047AMedicare PIN
I45649Medicare UPIN