Provider Demographics
NPI:1083873863
Name:PARK, SUZAN (OD)
Entity Type:Individual
Prefix:
First Name:SUZAN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 N GALLOWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-7415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1128 N GALLOWAY AVE
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-7415
Practice Address - Country:US
Practice Address - Phone:972-288-4427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7096TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8L13497Medicare PIN