Provider Demographics
NPI:1174785786
Name:PARK, TAE WOO (MD)
Entity type:Individual
Prefix:
First Name:TAE WOO
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TED
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3501 FORBES AVE FL 9
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-3317
Mailing Address - Country:US
Mailing Address - Phone:412-246-6351
Mailing Address - Fax:
Practice Address - Street 1:3501 FORBES AVE FL 9
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-3317
Practice Address - Country:US
Practice Address - Phone:412-246-6351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD146452084P0800X
MA2478862084P0800X, 2084P0802X
PAMD4365972084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110115275AMedicaid