Provider Demographics
NPI:1558380832
Name:PARK, JANG B (MD)
Entity Type:Individual
Prefix:DR
First Name:JANG
Middle Name:B
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 1:1216 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1242
Mailing Address - Country:US
Mailing Address - Phone:920-887-1922
Mailing Address - Fax:
Practice Address - Street 1:1575 S BERETANIA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-1149
Practice Address - Country:US
Practice Address - Phone:808-946-1712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI12897207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI55591Medicare UPIN
HI000016310Medicare ID - Type Unspecified