MEDICARE: DR. HERRI C PARK O.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	152W00000X	Optometrist	046-008581	IL

General Provider Information

NPI Number	:	1366568701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HERRI C PARK O.D.

Provider Business Mailing Address
First Line	:	1 OLD ORCHARD PLAZA
Second Line	:	OLD ORCHARD
City	:	SKOKIE
State	:	IL
Zip	:	60077
Country	:	US
Telephone Number	:	847-763-5882
Fax Number	:	847-763-5881

Provider Business Practice Location Address
First Line	:	5437 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-2222
Country	:	US
Telephone Number	:	773-561-1199
Fax Number	:

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

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	10/27/2016

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