Healthcare Provider Details

I. General information

NPI: 1437333515
Provider Name (Legal Business Name): JUN TAE PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

24701 EUCLID AVE 3RD FLOOR
EUCLID OH
44117-1714
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number5922577-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number35-097398
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: