Provider Demographics
NPI:1558359778
Name:PARK, JAY K (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:K
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6367 E TANQUE VERDE ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3832
Mailing Address - Country:US
Mailing Address - Phone:520-290-5888
Mailing Address - Fax:520-290-5551
Practice Address - Street 1:6367 E TANQUE VERDE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3832
Practice Address - Country:US
Practice Address - Phone:520-290-5888
Practice Address - Fax:520-290-5551
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ20616207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ04-06481OtherEVERCARE
AZAZ0710970OtherBLUE CROSS BLUE SHIELD
AZ168337Medicaid
AZ68458Medicare ID - Type Unspecified
AZAZ0710970OtherBLUE CROSS BLUE SHIELD