Provider Demographics
NPI:1073629200
Name:PARK, CHONGHYO THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:CHONGHYO
Middle Name:THOMAS
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 PRISCILLA LN
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2328
Mailing Address - Country:US
Mailing Address - Phone:201-541-7713
Mailing Address - Fax:
Practice Address - Street 1:44 SYLVAN AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2426
Practice Address - Country:US
Practice Address - Phone:201-242-1002
Practice Address - Fax:201-242-1012
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA68348208000000X
NY187394-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7931107Medicaid
G98231Medicare UPIN
NJ7931107Medicaid