Provider Demographics
NPI:1508872243
Name:PARK, JUNG MOK (MD)
Entity Type:Individual
Prefix:DR
First Name:JUNG
Middle Name:MOK
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:75 REMITTANCE DR
Mailing Address - Street 2:DEPT 6008
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-6008
Mailing Address - Country:US
Mailing Address - Phone:562-282-1419
Mailing Address - Fax:562-920-4642
Practice Address - Street 1:11480 BROOKSHIRE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-5026
Practice Address - Country:US
Practice Address - Phone:562-862-2775
Practice Address - Fax:562-904-8095
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA52223207V00000X
CA52223207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A522230OtherBLUE SHIELD
CA160055247OtherMEDICARE RAILROAD
CA00A522230Medicaid
CA160055247OtherRAILROAD MEDICARE
CA00A522230Medicaid
CA160055247OtherMEDICARE RAILROAD