Healthcare Provider Details

I. General information

NPI: 1235214131
Provider Name (Legal Business Name): CHARLES KEYU PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10099 RIDGEGATE PKWY STE 420
LONE TREE CO
80124-5536
US

IV. Provider business mailing address

10099 RIDGEGATE PKWY STE 420
LONE TREE CO
80124-5536
US

V. Phone/Fax

Practice location:
  • Phone: 303-800-6463
  • Fax: 303-500-6585
Mailing address:
  • Phone: 303-800-6463
  • Fax: 303-500-6585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberCDRH42664
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberCDRH42664
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: