Healthcare Provider Details

I. General information

NPI: 1700092103
Provider Name (Legal Business Name): CHAN HOON PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 VICTORY HWY
SLATERSVILLE RI
02876
US

IV. Provider business mailing address

905 VICTORY HWY PO BOX 177
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 NumberMD 5083
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: