Provider Demographics
NPI:1457417180
Name:PARK, CHONG H (MD, FRCS(US))
Entity Type:Individual
Prefix:DR
First Name:CHONG
Middle Name:H
Last Name:PARK
Suffix:
Gender:M
Credentials:MD, FRCS(US)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-1880
Mailing Address - Country:US
Mailing Address - Phone:973-509-3401
Mailing Address - Fax:973-655-1560
Practice Address - Street 1:775 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-1880
Practice Address - Country:US
Practice Address - Phone:973-509-3401
Practice Address - Fax:973-655-1560
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04390700207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine