Healthcare Provider Details

I. General information

NPI: 1275029084
Provider Name (Legal Business Name): JINWOOK PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 W WALNUT ST
INDIANAPOLIS IN
46202-5188
US

IV. Provider business mailing address

950 W WALNUT ST
INDIANAPOLIS IN
46202-5188
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-7453
  • Fax:
Mailing address:
  • Phone: 317-274-7453
  • Fax: 317-274-8575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01100306A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: