Provider Demographics
NPI:1912974122
Name:PARK, JANE GERKE (MD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:GERKE
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JANE
Other - Middle Name:CLAIRE
Other - Last Name:GERKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1002 SUSHRUTA DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-8897
Mailing Address - Country:US
Mailing Address - Phone:304-263-0913
Mailing Address - Fax:304-267-2917
Practice Address - Street 1:1002 SUSHRUTA DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-8897
Practice Address - Country:US
Practice Address - Phone:304-263-0913
Practice Address - Fax:304-267-2917
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0075526000Medicaid
WV0075526000Medicaid
PA0737042Medicare ID - Type Unspecified