Provider Demographics
NPI:1346297660
Name:PARK, TAE J (MD)
Entity type:Individual
Prefix:
First Name:TAE
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 S HAMPTON RD STE 322
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-5617
Mailing Address - Country:US
Mailing Address - Phone:469-501-9205
Mailing Address - Fax:469-629-1179
Practice Address - Street 1:306 S HAMPTON RD STE 322
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-5617
Practice Address - Country:US
Practice Address - Phone:469-501-9205
Practice Address - Fax:469-629-1179
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS1480207R00000X
CAA90047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A900470Medicaid
CA00A900470Medicaid
CAWA90047AMedicare PIN
I45649Medicare UPIN