MEDICARE: DR. KEVIN CHANIL 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	207R00000X	Internal Medicine Physician	154140	MA
2	207R00000X	Internal Medicine Physician	68021	WI

General Provider Information

NPI Number	:	1962437053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN CHANIL PARK M.D.

Provider Business Mailing Address
First Line	:	2161 WINDING STREAM WAY
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-8868
Country	:	US
Telephone Number	:	702-994-2958
Fax Number	:

Provider Business Practice Location Address
First Line	:	2161 WINDING STREAM WAY
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-8868
Country	:	US
Telephone Number	:	702-994-2958
Fax Number	:

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

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	07/16/2025

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