Healthcare Provider Details

I. General information

NPI: 1487003505
Provider Name (Legal Business Name): JINA PARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E RIDGEWOOD AVE STE 208
RIDGEWOOD NJ
07450-3937
US

IV. Provider business mailing address

1200 E RIDGEWOOD AVE STE 208
RIDGEWOOD NJ
07450-3937
US

V. Phone/Fax

Practice location:
  • Phone: 201-444-0868
  • Fax:
Mailing address:
  • Phone: 201-444-0868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number291837
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number25MA11105600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: