Provider Demographics
NPI:1588774921
Name:PARK, JIA (MD)
Entity type:Individual
Prefix:DR
First Name:JIA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210-08 35TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2979
Mailing Address - Country:US
Mailing Address - Phone:718-229-4090
Mailing Address - Fax:718-224-4131
Practice Address - Street 1:210-08 35TH AVENUE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2979
Practice Address - Country:US
Practice Address - Phone:718-229-4090
Practice Address - Fax:718-224-4131
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02180216Medicaid
NY3408D1Medicare ID - Type Unspecified
NY02180216Medicaid