Healthcare Provider Details

I. General information

NPI: 1861682189
Provider Name (Legal Business Name): JASON LEE PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 BELLE CHASSE HWY
TERRYTOWN LA
70056-7127
US

IV. Provider business mailing address

2500 BELLE CHASSE HWY
TERRYTOWN LA
70056-7127
US

V. Phone/Fax

Practice location:
  • Phone: 504-391-5157
  • Fax:
Mailing address:
  • Phone: 504-391-5157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD.202012
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA112590
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: