Provider Demographics
NPI:1740280551
Name:PAK, JAE H (MD)
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:H
Last Name:PAK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2160 FOUNTAIN DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-7022
Mailing Address - Country:US
Mailing Address - Phone:770-982-1111
Mailing Address - Fax:770-982-7280
Practice Address - Street 1:2160 FOUNTAIN DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-7022
Practice Address - Country:US
Practice Address - Phone:770-982-1111
Practice Address - Fax:770-982-7280
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2016-06-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0401852084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10594474OtherCAQH
GA000678477EMedicaid
GA26BDJZQOtherMEDICARE PTAN
GAF53884Medicare UPIN