Provider Demographics
NPI:1184156598
Name:LEE-PARK, JUNIPER (MD)
Entity type:Individual
Prefix:
First Name:JUNIPER
Middle Name:
Last Name:LEE-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 1:3030 BROOKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2504
Mailing Address - Country:US
Mailing Address - Phone:443-523-2457
Mailing Address - Fax:
Practice Address - Street 1:3800 RESERVOIR RD NW DEPT OF
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2113
Practice Address - Country:US
Practice Address - Phone:202-243-3400
Practice Address - Fax:202-243-3234
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.151779208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program