Provider Demographics
NPI:1144329723
Name:PARK, JAE H (DC)
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:H
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4840 IRVINE BLVD
Mailing Address - Street 2:#203
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1962
Mailing Address - Country:US
Mailing Address - Phone:714-665-2000
Mailing Address - Fax:714-665-2066
Practice Address - Street 1:4840 IRVINE BLVD
Practice Address - Street 2:#203
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-1962
Practice Address - Country:US
Practice Address - Phone:714-665-2000
Practice Address - Fax:714-665-2066
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26114111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ62362ZOtherBLUESHIELD
CAZZZ62362ZOtherBLUESHIELD
CADC26114Medicare ID - Type UnspecifiedCA MEDICARE