Provider Demographics
NPI:1023090206
Name:PARK, JEANNY KIM (MD)
Entity type:Individual
Prefix:DR
First Name:JEANNY
Middle Name:KIM
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2516 STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2208
Mailing Address - Country:US
Mailing Address - Phone:916-734-3589
Mailing Address - Fax:916-734-0424
Practice Address - Street 1:2516 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2208
Practice Address - Country:US
Practice Address - Phone:916-734-3589
Practice Address - Fax:916-734-0424
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG686722080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF33270Medicare UPIN