Healthcare Provider Details

I. General information

NPI: 1619940681
Provider Name (Legal Business Name): CHAN S. PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MICHUMI, PLLC DBA MED EXPRESS OF WILLIAMSBURG, VA 120 MONTICELLO AVE
WILLIAMSBURG VA
23185
US

IV. Provider business mailing address

PO BOX 5508
VIRGINIA BEACH VA
23471-0508
US

V. Phone/Fax

Practice location:
  • Phone: 757-564-3627
  • Fax: 757-564-6449
Mailing address:
  • Phone: 757-340-3489
  • Fax: 757-340-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101043881
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: