Provider Demographics
NPI:1053601161
Name:PARK, JUNG EUN (MD)
Entity type:Individual
Prefix:
First Name:JUNG
Middle Name:EUN
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 CHILDRENS LN
Mailing Address - Street 2:EVMS PEDIATRICS
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1910
Mailing Address - Country:US
Mailing Address - Phone:757-668-7272
Mailing Address - Fax:757-668-9766
Practice Address - Street 1:6345 CENTER DR BLDG 14
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4105
Practice Address - Country:US
Practice Address - Phone:757-461-4027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101256067208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAFP4504468OtherDEA