Provider Demographics
NPI:1003830340
Name:PARK, QUENTIN GIN (OD)
Entity Type:Individual
Prefix:DR
First Name:QUENTIN
Middle Name:GIN
Last Name:PARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 S LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-1608
Mailing Address - Country:US
Mailing Address - Phone:630-844-2500
Mailing Address - Fax:630-844-2599
Practice Address - Street 1:9 S LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:NORTH AURORA
Practice Address - State:IL
Practice Address - Zip Code:60542-1608
Practice Address - Country:US
Practice Address - Phone:630-844-2500
Practice Address - Fax:630-844-2599
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009672152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4584027OtherBCBS PIN
IL363187524OtherPHCS PIN
ILK11567OtherMEDICARE PROVIDER NUMBER
IL363187524OtherCIGNA
IL363187524OtherAETNA
IL363187524OtherAETNA
IL0155550001Medicare NSC
ILT37425Medicare UPIN
ILDG2164Medicare PIN