MEDICARE: DR. JIN SUP PARK MD

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	2085R0204X	Vascular & Interventional Radiology Physician	E8797	TX

General Provider Information

NPI Number	:	1962436550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JIN SUP PARK MD

Provider Business Mailing Address
First Line	:	8619 PASTURE VIEW LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-7039
Country	:	US
Telephone Number	:	713-686-0274
Fax Number	:	713-686-0274

Provider Business Practice Location Address
First Line	:	8619 PASTURE VIEW LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-7039
Country	:	US
Telephone Number	:	713-686-0274
Fax Number	:	713-686-0274

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/08/2007

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