Active NPI
Jae O Park, MD
- Internal Medicine Physician
- Beaverton, OR
National Provider Identifier
1780621805
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- License
- MD13752
- Practice address
- 14455 SW Allen Blvd
Suite 101
Beaverton, OR 97005-4428 - Phone
- (503) 643-2120
- Fax
- (503) 643-1034
- NPI assigned
- May 31, 2006
- Last updated
- Feb 24, 2017
- Sex
- Male
- Sole proprietor
- Yes
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 |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | MD13752 | OR | Primary |
Addresses
Primary practice location
14455 SW Allen Blvd
Suite 101
Beaverton, OR 97005-4428
Mailing address
12750 SW 2ND St
Ste 101
Beaverton, OR 97005-2779
Phone (503) 643-2120
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in OR
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20120228000765 | OR | Practitioner - Internal Medicine | 4789842345 | Practice locations: Beaverton, OR |
Care Compare profile
Medicare Care Compare- Specialty
- Internal Medicine
- Education
- Other, 1969
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
12750 SW 2ND St
Suite 101
Beaverton, OR 97005-2779
Phone (503) 643-2120
Hospital & facility affiliations
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 13752 | OR | MD | Massage Therapist |
Hospital & facility affiliations 1
Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.
-
dba Providence St Vincent Medical Center
- General Acute Care Hospital
- Portland, OR
- NPI 1114015971
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1149033600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1487894400000",
"number": "1780621805",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12750 SW 2ND ST",
"address_2": "STE 101",
"city": "BEAVERTON",
"state": "OR",
"postal_code": "970052779",
"telephone_number": "503-643-2120",
"fax_number": "503-643-1034"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "14455 SW ALLEN BLVD",
"address_2": "SUITE 101",
"city": "BEAVERTON",
"state": "OR",
"postal_code": "970054428",
"telephone_number": "503-643-2120",
"fax_number": "503-643-1034"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PARK",
"first_name": "JAE",
"middle_name": "O",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-05-31",
"last_updated": "2017-02-24",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "OR",
"license": "MD13752",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Beaverton, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 24, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.