Provider Demographics
NPI:1861438517
Name:PARK, CHARLES C (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
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 1:301 ST. PAUL PLACE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 ST. PAUL PLACE
Practice Address - Street 2:POB # 310
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202
Practice Address - Country:US
Practice Address - Phone:410-332-9872
Practice Address - Fax:410-659-1172
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0051977207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD388700600Medicaid
MDBU53/0001OtherCAREFIRST
G47595Medicare UPIN
420621/420617ZPX7Medicare PIN
S795 / 446VMedicare ID - Type Unspecified
MD461P 897GOtherMEDICARE
MDS186 / 0007OtherBLUECHOICE