Provider Demographics
NPI:1306894332
Name:PARK, CHAN J (MD)
Entity type:Individual
Prefix:DR
First Name:CHAN
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:20 S PLUM ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-3346
Practice Address - Country:US
Practice Address - Phone:605-624-9111
Practice Address - Fax:605-624-6636
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD5009208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7301822Medicaid
SD7301822Medicaid
SDS42295Medicare PIN