Healthcare Provider Details

I. General information

NPI: 1922680800
Provider Name (Legal Business Name): CHRISTOPHER PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 04/21/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 MADISON RD
CINCINNATI OH
45227-1491
US

IV. Provider business mailing address

2535 VALLEY VIEW CT
CINCINNATI OH
45219-1034
US

V. Phone/Fax

Practice location:
  • Phone: 513-272-2800
  • Fax: 513-272-2807
Mailing address:
  • Phone: 847-345-3210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: