Healthcare Provider Details

I. General information

NPI: 1861512592
Provider Name (Legal Business Name): JEAN YOUNG PARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BLVD RUSSELL MORGAN BLDG., 3RD FLOOR
BALTIMORE MD
21239-2905
US

IV. Provider business mailing address

5601 LOCH RAVEN BLVD RUSSELL MORGAN BLDG., 3RD FLOOR
BALTIMORE MD
21239-2905
US

V. Phone/Fax

Practice location:
  • Phone: 410-464-5600
  • Fax: 410-435-5367
Mailing address:
  • Phone: 410-464-5600
  • Fax: 410-435-5367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberD0061985
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: