Provider Demographics
NPI:1740629948
Name:PARK, CHANG S (MD)
Entity type:Individual
Prefix:DR
First Name:CHANG
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 1:200 OLD PALISADE RD APT 1E
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-7057
Mailing Address - Country:US
Mailing Address - Phone:201-592-0619
Mailing Address - Fax:
Practice Address - Street 1:200 OLD PALISADE RD APT 1E
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-7057
Practice Address - Country:US
Practice Address - Phone:201-592-0619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173037-1207R00000X
NJ25MA05299100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine