Provider Demographics
NPI:1316058076
Name:PARK, CHE SONG (MD,)
Entity type:Individual
Prefix:MR
First Name:CHE SONG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 BARRANCA PKWY
Mailing Address - Street 2:SUITE 330
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-8226
Mailing Address - Country:US
Mailing Address - Phone:949-552-8217
Mailing Address - Fax:949-809-9514
Practice Address - Street 1:3500 BARRANCA PKWY
Practice Address - Street 2:SUITE 330
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-8226
Practice Address - Country:US
Practice Address - Phone:949-552-8217
Practice Address - Fax:949-809-9514
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031253173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI280739862OtherBLUE CROSS BLUE SHIELD
MI2898621OtherHEALTHPLUS
MI280739862OtherBLUE CROSS BLUE SHIELD
MI2898621OtherHEALTHPLUS