Healthcare Provider Details

I. General information

NPI: 1881677854
Provider Name (Legal Business Name): CHANHI PARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 BUFORD RD
NORTH CHESTERFIELD VA
23235-3422
US

IV. Provider business mailing address

2602 BUFORD RD
NORTH CHESTERFIELD VA
23235-3422
US

V. Phone/Fax

Practice location:
  • Phone: 804-272-8806
  • Fax: 804-272-2909
Mailing address:
  • Phone: 804-272-8806
  • Fax: 804-272-2909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME66655
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101231753
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: