Provider Demographics
NPI:1093796047
Name:CHITTOM II, PARK THETFORD (MD)
Entity Type:Individual
Prefix:
First Name:PARK
Middle Name:THETFORD
Last Name:CHITTOM II
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 1:509 PARKMAN AVE
Mailing Address - Street 2:P.O. BOX 530
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-5734
Mailing Address - Country:US
Mailing Address - Phone:334-874-9064
Mailing Address - Fax:334-874-2633
Practice Address - Street 1:509 PARKMAN AVE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-5734
Practice Address - Country:US
Practice Address - Phone:334-874-9064
Practice Address - Fax:334-874-2633
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21882207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110180090OtherRAILROAD MEDICARE
AL000045614Medicaid
AL000045614Medicaid
ALG83377Medicare UPIN