Healthcare Provider Details

I. General information

NPI: 1558776062
Provider Name (Legal Business Name): CHRISTOPHER PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E BROAD ST
RICHMOND VA
23219-1928
US

IV. Provider business mailing address

PO BOX 780125
PHILADELPHIA PA
19178-0125
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-2467
  • Fax: 804-628-5848
Mailing address:
  • Phone: 804-922-4844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberMD211150
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number0101284351
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD211150
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberMD049177
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2018-00955
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30041
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: