Provider Demographics
NPI:1780621805
Name:PARK, JAE O (MD)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:O
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:12750 SW 2ND ST
Mailing Address - Street 2:STE 101
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2779
Mailing Address - Country:US
Mailing Address - Phone:503-643-2120
Mailing Address - Fax:503-643-1034
Practice Address - Street 1:14455 SW ALLEN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-4428
Practice Address - Country:US
Practice Address - Phone:503-643-2120
Practice Address - Fax:503-643-1034
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2017-02-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD13752207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine