Basic Information
| Provider Information | |||||||||
| NPI: | 1699015792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | JU | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1364 CLIFTON NERD D125A | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047124686 | ||||||||
| FaxNumber: | 4047127908 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 WOODRUFF CIR NE | ||||||||
| Address2: | SUITE 327 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303220001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047124686 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2013 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 007281 | GA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 007281 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.