Provider Demographics
NPI:1710040811
Name:PARK, CHANG J (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANG
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHANG JO
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3003 NEW HYDE PARK RD
Mailing Address - Street 2:#312
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042
Mailing Address - Country:US
Mailing Address - Phone:516-328-0505
Mailing Address - Fax:516-328-0409
Practice Address - Street 1:3003 NEW HYDE PARK RD
Practice Address - Street 2:#312
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-328-0505
Practice Address - Fax:516-328-0409
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120788207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C67083Medicare UPIN
94474Medicare ID - Type Unspecified