Provider Demographics
NPI:1760644280
Name:PARK, CHAN WOO (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAN
Middle Name:WOO
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:90 BERGEN STREET- SUITE 8100
Mailing Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY, DOC BUILDING
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103
Mailing Address - Country:US
Mailing Address - Phone:973-972-4588
Mailing Address - Fax:
Practice Address - Street 1:90 BERGEN STREET- SUITE 8100
Practice Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY, DOC BUILDING
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103
Practice Address - Country:US
Practice Address - Phone:973-972-4588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60287386207Y00000X
NJ25MA09356100207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1760644280Medicaid