Basic Information
| Provider Information | |||||||||
| NPI: | 1700939956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 478 BRICK BLVD | ||||||||
| Address2: | |||||||||
| City: | BRICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087236077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327014848 | ||||||||
| FaxNumber: | 7327011244 | ||||||||
| Practice Location | |||||||||
| Address1: | 478 BRICK BLVD | ||||||||
| Address2: | |||||||||
| City: | BRICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087236077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327014848 | ||||||||
| FaxNumber: | 7327011244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 10/24/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD434270 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | MD434270 | PA | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02188022 | 05 | NJ | MEDICAID |