Healthcare Provider Details

I. General information

NPI: 1962798397
Provider Name (Legal Business Name): JAE YOON PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MONUMENT RD
YORK PA
17403-5024
US

IV. Provider business mailing address

601 MEMORY LN
YORK PA
17402-2231
US

V. Phone/Fax

Practice location:
  • Phone: 717-851-2441
  • Fax:
Mailing address:
  • Phone: 717-851-1405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number55416
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberT292227
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number55416
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number69610
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberT292227
License Number StateMA
# 6
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD487523C
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: