Provider Demographics
NPI:1619322898
Name:PARK, JI-KWAN (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:JI-KWAN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:DR
Other - First Name:JI KWAN
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:1721 TECHNOLOGY DR DEPT 110
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95110-1305
Mailing Address - Country:US
Mailing Address - Phone:408-436-3350
Mailing Address - Fax:
Practice Address - Street 1:1721 TECHNOLOGY DR DEPT 110
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-1305
Practice Address - Country:US
Practice Address - Phone:408-436-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2023-08-14
Deactivation Date:2020-07-07
Deactivation Code:
Reactivation Date:2020-07-22
Provider Licenses
StateLicense IDTaxonomies
CAA155176207W00000X, 207WX0200X
IN01084888A207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty