Active NPI
Jean Paek
- Pediatrics Physician
- Upland, CA
National Provider Identifier
1992230965
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- PA62963
- Practice address
- 811 E 11TH St Ste 201
Upland, CA 91786-4872 - Phone
- (909) 985-0883
- NPI assigned
- Apr 26, 2017
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | |||
| Pediatrics Physician | 208000000X | PA62963 | CA | Primary |
Addresses
Primary practice location
811 E 11TH St Ste 201
Upland, CA 91786-4872
Mailing address
811 E 11TH St Ste 201
Upland, CA 91786-4872
Phone (909) 985-0883
Other practice location 1
16465 Sierra Lakes Pkwy Ste 115
Fontana, CA 92336-1242
Phone (909) 823-8000
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in KS
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20210719002900 | KS | Order and Referring Only - Pediatric Medicine | 4284037912 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA62963 | CA | MD | Pediatrics Physician |
Networks
- BSC 65 PLUS INDIVIDUAL MAPD
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1493164800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1694131200000",
"number": "1992230965",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "811 E 11TH ST STE 201",
"city": "UPLAND",
"state": "CA",
"postal_code": "917864872",
"telephone_number": "909-985-0883"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "811 E 11TH ST STE 201",
"city": "UPLAND",
"state": "CA",
"postal_code": "917864872",
"telephone_number": "909-985-0883"
}
],
"practiceLocations": [
{
"address_1": "16465 Sierra Lakes Pkwy Ste 115",
"address_purpose": "LOCATION",
"city": "Fontana",
"state": "CA",
"postal_code": "923361242",
"country_code": "US",
"telephone_number": "909-823-8000",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "PAEK",
"first_name": "JEAN",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2017-04-26",
"last_updated": "2023-09-08",
"certification_date": "2023-09-08",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": false
},
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "CA",
"license": "PA62963",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Upland, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.