Provider Demographics
NPI:1386816858
Name:PARK, JONG KEUN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONG
Middle Name:KEUN
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 1:232 BROAD AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1565
Mailing Address - Country:US
Mailing Address - Phone:201-346-0999
Mailing Address - Fax:
Practice Address - Street 1:232 BROAD AVE STE 208
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1565
Practice Address - Country:US
Practice Address - Phone:201-346-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08373800208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA08373800OtherNJ STATE LICENSE