Healthcare Provider Details

I. General information

NPI: 1154062578
Provider Name (Legal Business Name): CHRISTINE JEEWAN PARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 N TRUMAN BLVD
FESTUS MO
63028-1176
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 844-853-8937
  • Fax: 636-465-9512
Mailing address:
  • Phone: 314-577-5634
  • Fax: 636-465-9512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2025036642
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: