Active NPI
Jae Hong Park
- Otolaryngology Physician
- Detroit, MI
National Provider Identifier
1396407011
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Otolaryngology Physician
- License
- 4351048809
- Practice address
- 4100 John R St
Detroit, MI 48201-2013 - Phone
- (248) 854-4576
- NPI assigned
- Oct 11, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Otolaryngology Physician | 207Y00000X | 4351048809 | MI | Primary |
Addresses
Primary practice location
4100 John R St
Detroit, MI 48201-2013
Mailing address
1363 Dorothea Rd
Berkley, MI 48072-2148
Phone (248) 854-4576
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4351048809 | MI | MD | Otolaryngology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1633910400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1633910400000",
"number": "1396407011",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1363 DOROTHEA RD",
"city": "BERKLEY",
"state": "MI",
"postal_code": "480722148",
"telephone_number": "248-854-4576"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4100 JOHN R ST",
"city": "DETROIT",
"state": "MI",
"postal_code": "482012013",
"telephone_number": "248-854-4576"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PARK",
"first_name": "JAE",
"middle_name": "HONG",
"name_prefix": "Dr.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-10-11",
"last_updated": "2021-10-11",
"certification_date": "2021-10-11",
"status": "A"
},
"taxonomies": [
{
"code": "207Y00000X",
"taxonomy_group": "",
"desc": "Otolaryngology",
"state": "MI",
"license": "4351048809",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Detroit, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 11, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.