Provider Demographics
NPI:1992703409
Name:PARK, CHONG MIN (MD)
Entity type:Individual
Prefix:
First Name:CHONG
Middle Name:MIN
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 1:24 DOCTORS LN
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-8568
Mailing Address - Country:US
Mailing Address - Phone:814-226-7800
Mailing Address - Fax:814-226-7801
Practice Address - Street 1:24 DOCTORS LN
Practice Address - Street 2:SUITE 304
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-8568
Practice Address - Country:US
Practice Address - Phone:814-226-7800
Practice Address - Fax:814-226-7801
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428499207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C05681Medicare UPIN
PA188868Medicare PIN