Provider Demographics
NPI:1811554561
Name:PARK, JAE WAN (DAOM)
Entity Type:Individual
Prefix:
First Name:JAE WAN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DAOM
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DAOM
Mailing Address - Street 1:6225 FM 2920 RD STE 130
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-3474
Mailing Address - Country:US
Mailing Address - Phone:832-463-4526
Mailing Address - Fax:832-446-3631
Practice Address - Street 1:6225 FM 2920 RD STE 130
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-3474
Practice Address - Country:US
Practice Address - Phone:832-463-4526
Practice Address - Fax:832-446-3631
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01892171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist