Provider Demographics
NPI:1700092103
Name:PARK, CHAN HOON (MD)
Entity Type:Individual
Prefix:
First Name:CHAN
Middle Name:HOON
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 1:905 VICTORY HWY
Mailing Address - Street 2:PO BOX 177
Mailing Address - City:SLATERSVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02876
Mailing Address - Country:US
Mailing Address - Phone:401-762-2728
Mailing Address - Fax:401-762-0473
Practice Address - Street 1:905 VICTORY HWY
Practice Address - Street 2:
Practice Address - City:SLATERSVILLE
Practice Address - State:RI
Practice Address - Zip Code:02876
Practice Address - Country:US
Practice Address - Phone:401-762-2728
Practice Address - Fax:401-762-0473
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD 5083207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI001727OtherBLUE CHIP
RI1260-1OtherBLUE CROSS BLUE SHIELD
PR0100118OtherUNITED HEALTHCARE
RI9001260Medicaid
RI001727OtherBLUE CHIP