Provider Demographics
NPI:1629179411
Name:PARK, CHARLES W (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
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 1:405 NORTHFIELD AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-3026
Mailing Address - Country:US
Mailing Address - Phone:973-325-6120
Mailing Address - Fax:973-325-6126
Practice Address - Street 1:405 NORTHFIELD AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-3026
Practice Address - Country:US
Practice Address - Phone:973-325-6120
Practice Address - Fax:973-325-6126
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07374100101YM0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ059242BX1Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
NJH65934Medicare UPIN