Provider Demographics
NPI:1710181078
Name:PARK, CHRISTOPHER LANE (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:LANE
Last Name:PARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 CEDAR HILL DR
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-7262
Mailing Address - Country:US
Mailing Address - Phone:662-397-4597
Mailing Address - Fax:866-939-1560
Practice Address - Street 1:11 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-2807
Practice Address - Country:US
Practice Address - Phone:662-499-2802
Practice Address - Fax:866-939-1560
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06575065Medicaid
512I080150Medicare Oscar/Certification