Healthcare Provider Details

I. General information

NPI: 1659384774
Provider Name (Legal Business Name): CHAN H PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WOODLAND AVE
PHILADELPHIA PA
19104-4551
US

IV. Provider business mailing address

111 CAMELOT LN
NEWTOWN SQUARE PA
19073-4412
US

V. Phone/Fax

Practice location:
  • Phone: 215-823-6270
  • Fax:
Mailing address:
  • Phone: 610-353-0479
  • Fax: 215-823-4312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberMD031852L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License NumberMD031852L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: