Healthcare Provider Details

I. General information

NPI: 1104865849
Provider Name (Legal Business Name): CHAN PARK MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 VICTORY HIGHWAY
SLATERSVILLE RI
02876
US

IV. Provider business mailing address

PO BOX 177 905 VICTORY HWY
SLATERSVILLE RI
02876
US

V. Phone/Fax

Practice location:
  • Phone: 401-762-2728
  • Fax: 401-762-0473
Mailing address:
  • Phone: 401-762-2728
  • Fax: 401-762-0473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD5083
License Number StateRI

VIII. Authorized Official

Name: CHAN HOON PARK
Title or Position: OWNER
Credential: MD
Phone: 401-762-2728