Provider Demographics
NPI:1023086857
Name:PARK, JAY Y (MD, PC)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:Y
Last Name:PARK
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 S GARDEN WAY STE 230
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-8187
Mailing Address - Country:US
Mailing Address - Phone:541-747-6159
Mailing Address - Fax:541-741-7249
Practice Address - Street 1:360 S GARDEN WAY STE 230
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8187
Practice Address - Country:US
Practice Address - Phone:541-747-6159
Practice Address - Fax:541-741-7249
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20395207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR071634Medicaid
ORRR PTAN 070010885Medicare PIN
G39727Medicare UPIN
OR071634Medicaid