Provider Demographics
NPI:1083743991
Name:PARK, VANESSA CEBALLOS (OD)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:CEBALLOS
Last Name:PARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:VANESSA
Other - Middle Name:LEBITA
Other - Last Name:CEBALLOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:28638 QUEENSLAND DR
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7895
Mailing Address - Country:US
Mailing Address - Phone:951-378-8220
Mailing Address - Fax:
Practice Address - Street 1:375 E ALESSANDRO BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-2463
Practice Address - Country:US
Practice Address - Phone:951-789-6019
Practice Address - Fax:951-789-6036
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13083T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAV08075Medicare UPIN