Provider Demographics
NPI:1861485484
Name:PARK, CHAN SOO (MD)
Entity Type:Individual
Prefix:
First Name:CHAN SOO
Middle Name:
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 1:205 SOUTH AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-4818
Mailing Address - Country:US
Mailing Address - Phone:845-454-2360
Mailing Address - Fax:845-454-2361
Practice Address - Street 1:205 SOUTH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-4818
Practice Address - Country:US
Practice Address - Phone:845-454-2360
Practice Address - Fax:845-454-2361
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1271602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00503613Medicaid
C08958Medicare UPIN
NY00503613Medicaid