Provider Demographics
NPI:1518995869
Name:PARK, CHANKEE (MD)
Entity Type:Individual
Prefix:
First Name:CHANKEE
Middle Name:
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 1:16570 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1106
Mailing Address - Country:US
Mailing Address - Phone:586-263-7660
Mailing Address - Fax:586-286-4727
Practice Address - Street 1:16570 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1106
Practice Address - Country:US
Practice Address - Phone:586-263-7660
Practice Address - Fax:586-286-4727
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI037049207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4590264Medicaid
MIMI3925001Medicare PIN
MI4590264Medicaid
MI0E06281022Medicare ID - Type Unspecified