Provider Demographics
NPI:1184756082
Name:PARK, JUNG WON (MD)
Entity type:Individual
Prefix:DR
First Name:JUNG
Middle Name:WON
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:WON
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:877-860-2397
Practice Address - Street 1:7215 55TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2601
Practice Address - Country:US
Practice Address - Phone:916-399-1100
Practice Address - Fax:877-860-2397
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9781208000000X
CAC56214208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118238804Medicaid
TX89C759OtherBCBS
CAP01758328-DV5277OtherRR MEDICARE
CACA215513-CA140503Medicare PIN
TX89C759OtherBCBS