Provider Demographics
NPI:1346415247
Name:PARK, JACQUELINE JEEYUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:JEEYUNG
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2089 VALE RD
Mailing Address - Street 2:SUITE 33
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3847
Mailing Address - Country:US
Mailing Address - Phone:510-234-5012
Mailing Address - Fax:510-234-4921
Practice Address - Street 1:2089 VALE RD
Practice Address - Street 2:SUITE 33
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3847
Practice Address - Country:US
Practice Address - Phone:510-234-5012
Practice Address - Fax:510-234-4921
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY234855-1207RG0100X
CAA 109036207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACD912ZMedicare PIN