Provider Demographics
NPI:1043744279
Name:PARK, JUN (MD)
Entity type:Individual
Prefix:
First Name:JUN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUN
Other - Middle Name:BEOM
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8414 NAAB RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1972
Mailing Address - Country:US
Mailing Address - Phone:317-338-7510
Mailing Address - Fax:317-733-7539
Practice Address - Street 1:4150 V STREET, PSSB, SUITE G400
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817
Practice Address - Country:US
Practice Address - Phone:916-734-8328
Practice Address - Fax:651-333-4227
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA169512207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA169512OtherCALIFORNIA STATE MEDICAL LICENSE NUMBER