Provider Demographics
NPI:1013351840
Name:PAEK, DONGCHUL (DO)
Entity Type:Individual
Prefix:
First Name:DONGCHUL
Middle Name:
Last Name:PAEK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 POINTE WOODWORTH DR NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-3466
Mailing Address - Country:US
Mailing Address - Phone:201-625-2248
Mailing Address - Fax:
Practice Address - Street 1:1213 E TRINITY MILLS RD STE 173
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-1446
Practice Address - Country:US
Practice Address - Phone:972-962-1296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXS4835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060646710OtherMANCHESTER MEMORIAL HOSPITAL