Provider Demographics
NPI:1851317804
Name:PARK, WON B (MD)
Entity Type:Individual
Prefix:
First Name:WON
Middle Name:B
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 1:9000 TENNGA LN
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4586
Mailing Address - Country:US
Mailing Address - Phone:423-265-2271
Mailing Address - Fax:423-785-3454
Practice Address - Street 1:100 MOCCASIN BEND RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-4415
Practice Address - Country:US
Practice Address - Phone:423-265-2271
Practice Address - Fax:423-785-3454
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD123992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44-4002Medicare Oscar/Certification
TNE68263Medicare UPIN
TN3282227Medicare ID - Type UnspecifiedMEDICARE B