Provider Demographics
NPI:1942291638
Name:PARK, JUNG TAE (MD)
Entity Type:Individual
Prefix:MR
First Name:JUNG
Middle Name:TAE
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:13851 HIGHWAY 28
Mailing Address - City:WHITWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37397-0400
Mailing Address - Country:US
Mailing Address - Phone:423-658-9200
Mailing Address - Fax:423-658-2195
Practice Address - Street 1:13851 HIGHWAY 28
Practice Address - Street 2:
Practice Address - City:WHITWELL
Practice Address - State:TN
Practice Address - Zip Code:37397-5373
Practice Address - Country:US
Practice Address - Phone:423-658-9200
Practice Address - Fax:423-658-2195
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000010100207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2002139OtherB CARE
B029232Medicare UPIN
TN3162318Medicare PIN