Provider Demographics
NPI:1023124054
Name:PAK, JAESOO (MD)
Entity type:Individual
Prefix:DR
First Name:JAESOO
Middle Name:
Last Name:PAK
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 1:11841 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-6825
Mailing Address - Country:US
Mailing Address - Phone:562-809-8082
Mailing Address - Fax:
Practice Address - Street 1:11841 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6825
Practice Address - Country:US
Practice Address - Phone:562-809-8082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77845207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG77845OtherMEDICAL LICENSE NUMBER
CA00G077845Medicaid
CAG77845OtherMEDICAL LICENSE NUMBER