Healthcare Provider Details

I. General information

NPI: 1699329714
Provider Name (Legal Business Name): DR. TERRY PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7088 TRANSIT RD
BUFFALO NY
14221-7214
US

IV. Provider business mailing address

7088 TRANSIT RD
BUFFALO NY
14221-7214
US

V. Phone/Fax

Practice location:
  • Phone: 716-632-5497
  • Fax:
Mailing address:
  • Phone: 716-632-5497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV008958
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: