MEDICARE: DR. THERESA A PARK OD

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	2361T	OR

General Provider Information

NPI Number	:	1245368430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA A PARK OD

Provider Business Mailing Address
First Line	:	3030 GATEWAY STREET
Second Line	:	SEARS OPTICAL
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-1027
Country	:	US
Telephone Number	:	541-741-7049
Fax Number	:	541-744-2847

Provider Business Practice Location Address
First Line	:	3030 GATEWAY STREET
Second Line	:	SEARS OPTICAL
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-1027
Country	:	US
Telephone Number	:	541-741-7049
Fax Number	:	541-744-2847

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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