Provider Demographics
NPI:1417137365
Name:PARK, CHANDLER H (MD, MSC)
Entity Type:Individual
Prefix:DR
First Name:CHANDLER
Middle Name:H
Last Name:PARK
Suffix:
Gender:M
Credentials:MD, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2119
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-2119
Mailing Address - Country:US
Mailing Address - Phone:270-737-1212
Mailing Address - Fax:270-982-1210
Practice Address - Street 1:1263 HOSPITAL DR NW STE 110
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2173
Practice Address - Country:US
Practice Address - Phone:812-734-0912
Practice Address - Fax:502-629-2055
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48923207RH0003X
WV25614390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201083260Medicaid
OH57.013780OtherCREDENTIAL NUMBER
INP01150420OtherRAILROAD MEDICARE
INP01150420OtherRAILROAD MEDICARE