Provider Demographics
NPI:1669628228
Name:PARK, JAE MAN (MD)
Entity Type:Individual
Prefix:
First Name:JAE MAN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9535 GARDEN GROVE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1550
Mailing Address - Country:US
Mailing Address - Phone:714-534-1112
Mailing Address - Fax:714-534-1116
Practice Address - Street 1:9535 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1550
Practice Address - Country:US
Practice Address - Phone:714-534-1112
Practice Address - Fax:714-534-1116
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA105181207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine