Provider Demographics
NPI:1134484785
Name:PARK, LISA (OD)
Entity Type:Individual
Prefix:
First Name:LISA
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 1:1428 W HEBRON PKWY STE 125
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6345
Mailing Address - Country:US
Mailing Address - Phone:972-325-2022
Mailing Address - Fax:972-332-0308
Practice Address - Street 1:1428 W HEBRON PKWY STE 125
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6345
Practice Address - Country:US
Practice Address - Phone:972-325-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8206TG152W00000X
VA0618002164152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist