Provider Demographics
NPI:1699015792
Name:PARK, PETER JU (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JU
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 1:1364 CLIFTON NERD D125A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1059
Mailing Address - Country:US
Mailing Address - Phone:404-712-4686
Mailing Address - Fax:404-712-7908
Practice Address - Street 1:100 WOODRUFF CIR NE
Practice Address - Street 2:SUITE 327
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-0001
Practice Address - Country:US
Practice Address - Phone:404-712-4686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0072812085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology