Provider Demographics
NPI:1255336665
Name:PARK, CHAN H (MD)
Entity type:Individual
Prefix:DR
First Name:CHAN
Middle Name:H
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:STEVE
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:500 OLD RIVER RD STE 250
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-9515
Mailing Address - Country:US
Mailing Address - Phone:661-459-1010
Mailing Address - Fax:855-200-2829
Practice Address - Street 1:9500 STOCKDALE HWY
Practice Address - Street 2:SUITE 203
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-3620
Practice Address - Country:US
Practice Address - Phone:661-587-8110
Practice Address - Fax:661-587-8220
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA068509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH13305Medicare UPIN