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General NPI Number Information
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NPI Number | 1720061914
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Entity Type | Organization
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Legal Business Name | PARK OPTOMETRY, INC
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Dates
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Enumeration Date | 11/22/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1939 GRAND AVE
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City | SAN DIEGO
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State | CA
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Zip | 92109-4508
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Country | US
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Telephone | 858-272-2211
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Fax |
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Provider Business Mailing Address
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Address Line | 1939 GRAND AVE
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City | SAN DIEGO
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State | CA
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Zip | 92109-4508
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DAVID PARK
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Credential | O.D.
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Telephone | 858-272-2211
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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 | 10394T
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License Number State | CA
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