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General NPI Number Information
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NPI Number | 1366633257
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Entity Type | Organization
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Legal Business Name | JAESOO PAK, MD
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Dates
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Enumeration Date | 08/06/2007
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Last Update Date | 06/19/2008
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Provider Practice Location Address
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Address Line | 11845 SOUTH ST
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City | CERRITOS
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State | CA
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Zip | 90703-6825
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Country | US
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Telephone | 562-809-2103
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Fax |
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Provider Business Mailing Address
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Address Line | 11845 SOUTH ST
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City | CERRITOS
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State | CA
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Zip | 90703-6825
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Country | US
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Telephone | 562-809-2103
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. JAESOO PAK
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Credential | M.D.
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Telephone | 562-809-2103
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QE0800X
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Taxonomy Name | Endoscopy Clinic/Center
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License Number | 05-C0001451
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License Number State | CA
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