Provider Demographics
NPI:1700147378
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:DR
Other - First Name:CHAN
Other - Middle Name:H
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:22226 CLIFF AVE S
Mailing Address - Street 2:#304
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-4619
Mailing Address - Country:US
Mailing Address - Phone:253-946-9365
Mailing Address - Fax:253-946-9365
Practice Address - Street 1:22226 CLIFF AVE S
Practice Address - Street 2:#304
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-4619
Practice Address - Country:US
Practice Address - Phone:253-946-9365
Practice Address - Fax:253-946-9365
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28108207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine