Provider Demographics
NPI:1992800353
Name:PARK, JIN HEWA (DO)
Entity type:Individual
Prefix:DR
First Name:JIN
Middle Name:HEWA
Last Name:PARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:JIN
Other - Middle Name:WHA
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:19702 SHEILA CT
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-3272
Mailing Address - Country:US
Mailing Address - Phone:909-598-7147
Mailing Address - Fax:
Practice Address - Street 1:250 W SAN JOSE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-5207
Practice Address - Country:US
Practice Address - Phone:909-399-2063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC11584GMedicaid
CAG56344Medicare UPIN