Provider Demographics
NPI:1619126323
Name:CHANUN PARK DO PA
Entity Type:Organization
Organization Name:CHANUN PARK DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANUN
Authorized Official - Middle Name:DUSTIN
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-369-4155
Mailing Address - Street 1:1220 BUSINESS WAY
Mailing Address - Street 2:UNIT 1
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-6007
Mailing Address - Country:US
Mailing Address - Phone:239-369-4155
Mailing Address - Fax:239-369-1950
Practice Address - Street 1:1220 BUSINESS WAY
Practice Address - Street 2:UNIT 1
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-6007
Practice Address - Country:US
Practice Address - Phone:239-369-4155
Practice Address - Fax:239-369-1950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8128261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL51729Medicare PIN