Provider Demographics
NPI:1336230259
Name:PARK, TAE K (MD)
Entity type:Individual
Prefix:
First Name:TAE
Middle Name:K
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4204
Mailing Address - Country:US
Mailing Address - Phone:718-768-8111
Mailing Address - Fax:718-768-8111
Practice Address - Street 1:724 8TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4204
Practice Address - Country:US
Practice Address - Phone:718-768-8111
Practice Address - Fax:718-768-8111
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152709207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00775604Medicaid
NY00775604Medicaid
A59823Medicare UPIN