Provider Demographics
NPI:1528656170
Name:PARK, JASON S (MD, PHARMD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:MD, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-3776
Mailing Address - Country:US
Mailing Address - Phone:484-822-5205
Mailing Address - Fax:833-214-9836
Practice Address - Street 1:400 S GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-3776
Practice Address - Country:US
Practice Address - Phone:484-822-5205
Practice Address - Fax:833-214-9836
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP446664183500000X
PAMT227888207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No183500000XPharmacy Service ProvidersPharmacist