MEDICARE: DR. CHAN H. PARK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A068509	CA

General Provider Information

NPI Number	:	1255336665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHAN H. PARK M.D.

Provider Business Mailing Address
First Line	:	500 OLD RIVER RD STE 250
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93311-9515
Country	:	US
Telephone Number	:	661-459-1010
Fax Number	:	855-200-2829

Provider Business Practice Location Address
First Line	:	9500 STOCKDALE HWY
Second Line	:	SUITE 203
City	:	BAKERSFIELD
State	:	CA
Zip	:	93311-3620
Country	:	US
Telephone Number	:	661-587-8110
Fax Number	:	661-587-8220

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	12/03/2020

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