Provider Demographics
NPI:1700863198
Name:PARK, CHRISTOPHER WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:WILLIAM
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 1:3509 N 34TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-5703
Mailing Address - Country:US
Mailing Address - Phone:573-356-5886
Mailing Address - Fax:
Practice Address - Street 1:13280 EVENING CREEK DR S
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-4101
Practice Address - Country:US
Practice Address - Phone:858-546-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA896722085R0202X
MO20080255722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360032Medicare PIN
CARES000Medicare UPIN