Provider Demographics
NPI:1275554610
Name:PARK, CHANG S S (MD)
Entity Type:Individual
Prefix:
First Name:CHANG S
Middle Name:S
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 1:118 BROAD AVE N9
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650
Mailing Address - Country:US
Mailing Address - Phone:201-482-0439
Mailing Address - Fax:201-482-8703
Practice Address - Street 1:118 BROAD AVE N9
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650
Practice Address - Country:US
Practice Address - Phone:201-482-0439
Practice Address - Fax:201-482-8703
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-08-02
Deactivation Date:2016-04-18
Deactivation Code:
Reactivation Date:2016-05-10
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07699600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA136832QH0Medicare ID - Type Unspecified