Provider Demographics
NPI:1962798397
Name:PARK, JAE YOON (MD)
Entity type:Individual
Prefix:
First Name:JAE YOON
Middle Name:
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 1:555 E RIVER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-5843
Mailing Address - Country:US
Mailing Address - Phone:520-838-3540
Mailing Address - Fax:520-325-3526
Practice Address - Street 1:4729 E CAMP LOWELL DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1256
Practice Address - Country:US
Practice Address - Phone:520-838-3540
Practice Address - Fax:520-318-0104
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55416207R00000X, 207RC0000X
MAT292227207RC0000X, 207RI0011X
AZ69610207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110015512Medicare PIN