Provider Demographics
NPI:1861682189
Name:PARK, JASON LEE (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
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 1:2500 BELLE CHASSE HWY
Mailing Address - Street 2:
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-7127
Mailing Address - Country:US
Mailing Address - Phone:504-391-5157
Mailing Address - Fax:
Practice Address - Street 1:2500 BELLE CHASSE HWY
Practice Address - Street 2:
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-7127
Practice Address - Country:US
Practice Address - Phone:504-391-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.202012207L00000X
CAA112590207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02470860Medicaid
LA1000922Medicaid
LA1000922Medicaid
MS02470860Medicaid