Healthcare Provider Details

I. General information

NPI: 1700834777
Provider Name (Legal Business Name): JUNG K PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11209 N TATUM BLVD SUITE #110
PHOENIX AZ
85028-3091
US

IV. Provider business mailing address

PO BOX 14687
SCOTTSDALE AZ
85267-4687
US

V. Phone/Fax

Practice location:
  • Phone: 602-248-8002
  • Fax: 602-248-8399
Mailing address:
  • Phone: 480-991-8100
  • Fax: 480-922-1028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number26466
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberF91378
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: