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General NPI Number Information
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NPI Number | 1861485484
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Entity Type | Individual
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Provider Name | CHAN SOO PARK MD
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Gender | Male
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Dates
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Enumeration Date | 08/30/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 205 SOUTH AVE SUITE 103
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City | POUGHKEEPSIE
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State | NY
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Zip | 12601-4818
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Country | US
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Telephone | 845-454-2360
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Fax | 845-454-2361
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Provider Business Mailing Address
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Address Line | 205 SOUTH AVE SUITE 103
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City | POUGHKEEPSIE
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State | NY
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Zip | 12601-4818
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Country | US
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Telephone | 845-454-2360
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Fax | 845-454-2361
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 127160
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License Number State | NY
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