Provider Demographics
NPI:1942427117
Name:PARK, MICHAEL CHANKWON (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHANKWON
Last Name:PARK
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Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC96, D429 MAIL
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-626-4706
Mailing Address - Fax:612-624-0644
Practice Address - Street 1:516 DELAWARE ST SE
Practice Address - Street 2:CLINIC 1A
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-624-6666
Practice Address - Fax:612-624-0644
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2014-12-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN58653207T00000X
KYTP326207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery