Provider Demographics
NPI:1790129898
Name:PARK, JANE J (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:J
Last Name:PARK
Suffix:
Gender:F
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-652-4111
Mailing Address - Fax:239-652-4105
Practice Address - Street 1:13279 N CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-4818
Practice Address - Country:US
Practice Address - Phone:239-652-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132432208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102359500Medicaid