Provider Demographics
NPI:1619940681
Name:PARK, CHAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAN
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:PO BOX 5508
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23471-0508
Mailing Address - Country:US
Mailing Address - Phone:757-340-3489
Mailing Address - Fax:757-340-4278
Practice Address - Street 1:MICHUMI, PLLC DBA MED EXPRESS OF WILLIAMSBURG, VA
Practice Address - Street 2:120 MONTICELLO AVE
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185
Practice Address - Country:US
Practice Address - Phone:757-564-3627
Practice Address - Fax:757-564-6449
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043881207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010094321Medicaid
VAP00153223OtherRRMED
VA00W070M02Medicare PIN
VAP00153223OtherRRMED