Provider Demographics
NPI:1366633257
Name:JAESOO PAK, MD
Entity Type:Organization
Organization Name:JAESOO PAK, MD
Other - Org Name:CERRITOS ENDOSCOPIC MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAESOO
Authorized Official - Middle Name:
Authorized Official - Last Name:PAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-809-2103
Mailing Address - Street 1:11845 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-6825
Mailing Address - Country:US
Mailing Address - Phone:562-809-2103
Mailing Address - Fax:
Practice Address - Street 1:11845 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6825
Practice Address - Country:US
Practice Address - Phone:562-809-2103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
CA05-C0001451261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS051451Medicare PIN