Provider Demographics
NPI:1073517801
Name:PARK, MARK J (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
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 1:919 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-2202
Mailing Address - Country:US
Mailing Address - Phone:661-725-3795
Mailing Address - Fax:661-725-3797
Practice Address - Street 1:919 13TH AVE
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-2202
Practice Address - Country:US
Practice Address - Phone:661-725-3795
Practice Address - Fax:661-725-3797
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2012-08-30
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
CAOPT10152T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0101520Medicaid
CASD0101520Medicaid
CACZ764AMedicare PIN