MEDICARE: DR. JEANNY KIM PARK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0202X	Pediatric Cardiology Physician	G68672	CA

General Provider Information

NPI Number	:	1023090206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEANNY KIM PARK M.D.

Provider Business Mailing Address
First Line	:	2516 STOCKTON BLVD
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95817-2208
Country	:	US
Telephone Number	:	916-734-3589
Fax Number	:	916-734-0424

Provider Business Practice Location Address
First Line	:	2516 STOCKTON BLVD
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95817-2208
Country	:	US
Telephone Number	:	916-734-3589
Fax Number	:	916-734-0424

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	10/25/2007

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