=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609819614
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SONYA MINHA PARK M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 05/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10300 S DE ANZA BLVD
-----------------------------------------------------
City | CUPERTINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95014-3030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-252-7310
-----------------------------------------------------
Fax | 408-257-8355
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 393 BLOSSOM HILL RD STE 265
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95123-1652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-227-7122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4527
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT14382-TPL
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------