Provider Demographics
NPI:1669994935
Name:PARK, JI SEOK (MD)
Entity type:Individual
Prefix:DR
First Name:JI SEOK
Middle Name:
Last Name:PARK
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 1:9500 EUCLID AVE A51
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-1913
Mailing Address - Country:US
Mailing Address - Phone:216-219-3551
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE A51
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44193-1913
Practice Address - Country:US
Practice Address - Phone:216-219-3551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-08
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.138824207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program