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General NPI Number Information
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NPI Number | 1154941367
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Entity Type | Individual
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Provider Name | DR. SUN MYUNG PARK
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Gender | Male
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Dates
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Enumeration Date | 04/17/2020
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Last Update Date | 04/07/2021
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Provider Practice Location Address
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Address Line | 11017 APOGEE CIR APT 2314
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City | FORT WORTH
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State | TX
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Zip | 76244-2596
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Country | US
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Telephone | 631-834-5221
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Fax |
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Provider Business Mailing Address
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Address Line | 3016 TEXAS SAGE TRL
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City | FORT WORTH
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State | TX
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Zip | 76177-8589
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Country | US
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Telephone | 631-834-5221
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 10097T
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License Number State | TX
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