Provider Demographics
NPI:1700939956
Name:PARK, JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:
Last Name: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 1:478 BRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-6077
Mailing Address - Country:US
Mailing Address - Phone:732-701-4848
Mailing Address - Fax:732-701-1244
Practice Address - Street 1:478 BRICK BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-6077
Practice Address - Country:US
Practice Address - Phone:732-701-4848
Practice Address - Fax:732-701-1244
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD434270208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ02188022Medicaid
PA057813Medicare PIN
NJ167396Medicare PIN