Provider Demographics
NPI:1457467037
Name:PARK, CHAN M (MD)
Entity Type:Individual
Prefix:
First Name:CHAN
Middle Name:M
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 1:6460 GREENSBORO RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:VA
Mailing Address - Zip Code:24148-3478
Mailing Address - Country:US
Mailing Address - Phone:276-956-2047
Mailing Address - Fax:276-956-1637
Practice Address - Street 1:6460 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:VA
Practice Address - Zip Code:24148-3478
Practice Address - Country:US
Practice Address - Phone:276-956-2047
Practice Address - Fax:276-956-1637
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101229138207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010011019Medicaid
VA463669OtherANTHEM, BCBS OF VIRGINIA
A1738OtherMEDCOST PREFERRED
3506280OtherCIGNA
0005372768OtherAETNA
2108815OtherMAMSI
VA463669OtherANTHEM, BCBS OF VIRGINIA
A1738OtherMEDCOST PREFERRED
VA010011019Medicaid