Provider Demographics
NPI:1821456856
Name:PARK, CHUNGHEON
Entity Type:Individual
Prefix:
First Name:CHUNGHEON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3135
Mailing Address - Country:US
Mailing Address - Phone:703-801-2003
Mailing Address - Fax:
Practice Address - Street 1:5018 DORSEY HALL DR
Practice Address - Street 2:SUTIE 205
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7855
Practice Address - Country:US
Practice Address - Phone:703-801-2003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02262171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist