Provider Demographics
NPI:1013972702
Name:PARK, JAI S (MD)
Entity Type:Individual
Prefix:DR
First Name:JAI
Middle Name:S
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 1:310 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1613
Mailing Address - Country:US
Mailing Address - Phone:618-939-8161
Mailing Address - Fax:
Practice Address - Street 1:1 JEFFERSON BARRACKS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-4181
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO356152081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOVAD000Medicare UPIN